Shoulder pain within the ICF framework;

patient experiences of functioning and assessment methods

Doctoral thesis by Yngve Røe

Faculty of Medicine, University of Oslo

Faculty of Health Sciences, Oslo and Akershus University College of Applied

Sciences

Department of Physical Medicine and Rehabilitation, Oslo University Hospital -

Ullevål
© Yngve Røe, 2014

Series of dissertations submitted to the

Faculty of Medicine, University of Oslo
No. 1741

ISBN 978-82-8264-790-8

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The thesis is produced by Akademika Publishing merely in connection with the
thesis defence. Kindly direct all inquiries regarding the thesis to the copyright
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 TABLE OF CONTENTS

ACKNOWLEDGEMENTS
LIST OF ORIGINAL PAPERS
ABSTRACT
ABBREVATIONS

1. INTRODUCTION ................................................................................................................1
1.1 International Classification of Functioning, Disability and Health (ICF) ......................... 1
1.1.1 History and theoretical underpinnings ................................................................... 1
1.1.2 Conceptual framework and classification .............................................................. 2
1.1.3 ICF Core Sets for specific conditions or settings ................................................... 4
1.1.4 The Generic ICF Core Set .................................................................................... 4
1.1.5 Application of the ICF in rehabilitation ................................................................... 5
1.2 Shoulder pain .............................................................................................................. 5
1.2.1 Prevalence, incidence, clinical course and classification ....................................... 6
1.2.2 Subjective experiences of functioning ................................................................... 7
1.2.3 Assessment of body functions and structures ....................................................... 8
1.2.4 Assessment of activities and participation ............................................................. 9
1.2.5 Assessment of environmental factors ..................................................................10
2. AIMS OF THE PROJECT .................................................................................................10
3. MATERIAL AND METHODS ............................................................................................11
3.1 Design ........................................................................................................................11
3.2 Subjects......................................................................................................................11
3.3 Material.......................................................................................................................12
3.3.1 Literature review of measures ..............................................................................12
3.3.2 Patient interviews .................................................................................................13
3.3.3 Development of a clinician-rated activity measure ...............................................14
3.4 Analyses .....................................................................................................................15
3.4.1 Content analyses .................................................................................................15
3.4.2 Statistical analyses ..............................................................................................16
4. MAIN RESULTS ...............................................................................................................17
4.1 Literature review of measures (Paper I) ......................................................................17
4.2 Patient interviews (Paper II) ........................................................................................19
4.3 Patient experiences in relation to the content of measures (Paper III) ........................20
4.4 A preliminary list of ICF categories for shoulder pain (Thesis) ....................................23
4.5 Reliability of the clinician-rated activity measure (Paper IV) ........................................29
5. DISCUSSION ...................................................................................................................30
5.1 Methodological considerations....................................................................................30
5.1.1 Subjects and material ..........................................................................................30
5.1.2 Procedures and measures ...................................................................................32
5.1.3 Analyses ..............................................................................................................33
5.2 Result discussion........................................................................................................34
5.2.1 Patient experiences in relation to the content of measures ..................................34
5.2.2 Content variation in condition-specific measures .................................................36
5.2.3 The added value of clinician-rated movement measures .....................................37
5.2.4 A comprehensive picture of shoulder pain within the ICF framework ...................38
5.2.5 Benefit of condition-specific ICF categories .........................................................40
6. CONCLUSIONS ...............................................................................................................41
6.1 Conclusions ................................................................................................................41
6.2 Implications for clinical practice and research .............................................................43
7. REFERENCES .................................................................................................................44

PAPERS I-IV

APPENDIXES
ACKNOWLEDGEMENTS

This study was financed by the Faculty of Health Sciences at the Oslo and Akershus
University College (HIOA). Their contribution is greatly appreciated.

My sincere thanks go to my main supervisor, Associate Professor Helene Lundgaard

Søberg, and my second supervisors, Associate Professor Sigrid Østensjø and Professor Erik
Bautz-Holter. Without their substantial contributions and invaluable support I would never
have been able to complete this work!

My thanks are also expressed to the staff in the outpatient clinic at the department of
Physical Medicine and Rehabilitation, Oslo University Hospital Ullevaal who contributed to
the inclusion of patients. A person who deserves special mention is Dr. Niels Gunnar Juel,
for his commitment and contribution in the inclusion of patients and co-authorship. I owe
special thanks to Dr. Heinrich Gall and other members at the ICF Research Branch in
Germany and Switzerland for technical consultation and support. I am also very grateful to
Research Librarian Marit Isaksen for counselling in the development of a search strategy in
the literature review. Special thanks as well to Kaia Engebretsen for help in the analyses and
co-authorship of one of the papers.

Further warm thanks go to Benjamin Haldorsen, Ida Svege and other members of the staff at
the Department of Physiotherapy at Martina Hansens Hospital, Bærum for cooperation in our
common research project. I am also very grateful to Professor Astrid Bergland at the Institute
of Physiotherapy, HIOA for her faith in the project and for her co-authorship of one of the
papers.

Several people at the Department of Physiotherapy, HIOA have contributed. I owe special
thanks to the former head of the department, Nina Bugge Rigault for her unreserved support
and interest in my PhD-project. I also want to thank the current head of the Department of
Physiotherapy, Hege Bentzen, and all my colleagues at the department for encouragement
and help throughout the project.

Finally, I want to thank my family, Elisabeth, Karen and Ole Jakob for their patience and
encouragement through this truly demanding period.

Oslo September 2013

Yngve Røe
LIST OF ORIGINAL PAPERS

I Roe Y, Soberg HL, Bautz-Holter E, Ostensjo S: A systematic review of measures of

shoulder pain and functioning using the International Classification of Functioning,

Disability and Health (ICF). BMC Musculoskelet Disorders 2013, 14:73.

II Roe Y, Bautz-Holter E, Juel NG, Soberg HL: Identification of relevant International

Classification of Functioning, Disability and Health categories in patients with shoulder

pain: A cross-sectional study. Journal of Rehabilitation Medicine 2013, 45(7):662-669.

III Roe Y, Ostensjo S, Bautz-Holter E, Juel NG, Engebretsen K, Soberg HL: Do the

current measures of shoulder pain match patient-reported problems in functioning? A

comparison based on the ICF. Disability and Rehabilitation, under review Sept. 2013.

IV Roe Y, Haldorsen B, Svege I, Bergland A: Development and Reliability of a Clinician-

rated Instrument to Evaluate Function in Individuals with Shoulder Pain: A Preliminary

Study. Physiotherapy Research International 2013, 28(10).

ABSTRACT

Introduction: Shoulder pain is a common, persistent and disabling disease. The restoration
of abnormal movement-patterns is often an important goal in the treatment of patients with
shoulder pain. The International Classification of Functioning, Disability and Health (ICF) is a
conceptual framework and classification that has been developed by the World Health
Organisation. The ICF is a common, multi-disciplinary language that allows identification of
condition-specific codes (ICF categories), comparison between patient-experiences of
functioning and assessment tools and development of new measures.
Aims: The aims of this thesis are to identify the ICF categories that reflect the concepts used
in assessment of shoulder pain and identify the ICF categories that reflect problems related
to functioning and interactions with the environment in patients with shoulder pain. As an
extension of this aim, whether patient experiences of functioning are captured by the present
assessment tools is also investigated. Moreover, the ICF categories that reflect the patient-
experiences of functioning and the content of the assessment tools are used to create a
preliminary list of ICF categories for shoulder pain. Finally, a clinician-rated activity measure
to capture abnormal movement patterns in the upper extremities is developed and tested.
Methods: The present work is based on three studies: a literature review of measures, a
cross-sectional study with patient interviews and a test-retest study. In addition, the datasets
from the literature review of measures and the cross-sectional study with patient interviews
constitute the material used for the comparison of the patient-experiences of functioning and
the content of measures, and for the development of a preliminary list of ICF categories for
shoulder pain. In the literature review, articles that were written in English, published in peer-
reviewed journals and based on clinical studies that included patients with shoulder pain
aged 18 years and older were included. Studies on patients with fractures, joint replacement,
complete dislocation, malignant condition, rheumatic diagnosis and stroke were excluded.
The measures extracted from the articles were linked to ICF categories according to
standardised rules. The frequency of the identified ICF categories was calculated and
reported for categories with a frequency of at least 1%. In the cross-sectional study, patients
in the outpatient clinic at the Department of Physical Medicine and Rehabilitation, Ullevaal
University Hospital, were included. The inclusion and exclusion criteria were similar to those
in the literature review. The patients were interviewed with a condition-adapted ICF checklist
that contained 154 categories. The presence of a functional problem or environmental factor
according to these ICF categories was registered. The ICF categories that were registered
with a frequency of at least 5% were reported. The correspondence between these two
datasets was investigated using the following criteria: (1) categories included in both
datasets with similar rankings, (2) categories included in both datasets with different
rankings, and (3) categories included in only one of the datasets. In addition, the match
between high frequent patient-derived ICF categories (reported by ≥ 50 %) and the content
of frequently cited condition-specific measures (identified with ≥ 10 citations) was
investigated. The preliminary list of ICF categories for shoulder pain was constituted from all
the ICF categories that were reported in the cross-sectional study with patient interviews and
the literature review of measures. Finally, a simple, clinician-rated activity measure was
developed and reliability tested. The development process was based on identification of
eligible items in the literature, pilot-testing and statistical analyses. The test-retest study was
conducted at the Department of Physiotherapy at Martina Hansens Hospital, Baerum.
Patients aged 18 years and older with a main diagnosis of subacromial impingement
syndrome were included. The exclusion criteria were similar to those from the literature
review and the cross-sectional study. Item-reduction was based on item-to-sum correlations.
In the further testing of the final scale, inter- and intra-rater reliability were calculated with the
Interclass Correlation Coefficient (ICC) and a 95% Confidence Interval (CI). The minimal
detectable change was calculated from the standard error. The content of the scale was
linked to ICF categories according to the established rules.
Results: In the literature review, 40 ICF categories were identified in 475 measures. Of
these, 28 belonged to activities and participation, 11 to body functions and structures and 1
to environmental factors. In the cross-sectional study with patient interviews, 165 patients
with a mean age of 46.5 years (SD = 12.5) were included. A total of 61 ICF categories were
identified. Of these, 19 covered body functions and structures, 34 activities and participation,
and 8 environmental factors. The correspondence between the two datasets was high for
activities and participation, and lower for body functions and structures and environmental
factors. In particular, patient-derived mental- and muscle body functions and environmental
social support were not present in the measures. Moreover, 6 high frequent patient-derived
categories are not matched by the content of any of the most frequently selected condition-
specific scales. The American Shoulder and Elbow Surgeons Standardized Form for
Assessment of the Shoulder (ASES) and the Disability of the Arm, Shoulder and Hand
(DASH) scale match the highest number of high frequent patient-derived categories. The
preliminary list of ICF categories for shoulder pain contains a total of 68 second-level ICF
categories. Of these more than half belong to activities and participation. In the test-retest
study, a total of 63 patients, aged 53.3 (SD = 12.9) and diagnosed with subacromial
impingement syndrome, were included. A clinician-rated activity measure, the Shoulder
Activity Scale, with 3 items and a summed score ranging from 3 to 15 was developed. The
inter-rater reliability and test-retest reliability were ICC = 0.80 (95% CI = 0.51 - 0.90) and ICC
= 0.74 (95% CI = 0.58 - 0.84), respectively. The minimal detectable change of the scale was
calculated as 3.32. The scale covers the ICF categories lifting and carrying objects (d430),
dressing (d540), hand and arm use (d445) and control of voluntary movement (b760).
Conclusions: The patient experiences of shoulder pain are multi-faceted, covering the ICF
body functions sensation of pain, movement-related functions and mental functions and the
activity and participation functions mobility, self-care, domestic life, interpersonal interactions
and relationships, work and leisure activities. Except for social support from immediate family
and friends, environmental factors were scarcely represented. The assessments of patients
with shoulder pain only partially capture the patient experiences of functioning and there is
large variation in the content of condition-specific measures. These findings have
implications for clinicians and researchers in the selection of measures. The Shoulder
Activity Scale is a simple and reliable measure that fills a gap in the assessment of patients
with shoulder pain. Before it is applied in clinical settings, it needs to be validated. For the
first time, a preliminary list of ICF categories for shoulder pain is presented. The preliminary
list should be further developed with contributions from qualitative patient interviews, an
expert survey and a formalised decision process.
ABBREVATIONS

ASES = American Shoulder and Elbow Surgeons Standardized Form for

Assessment of the Shoulder.
Constant = Constant-Murley Shoulder Score.
DASH = Disability of the Arm, Shoulder and Hand Scale.
ICD = International Statistical Classification of Diseases and Related Health
Problems.
ICF = International Classification of Functioning, Disability and Health.
ICIDH = International Classification of Impairments, Disabilities and Handicaps.
OSS = Oxford Shoulder Score.
Rowe = Rating Sheet for Bankart Repair.
SDQ = Shoulder Disability Questionnaire.
SF-36 = Medical Outcomes Study 36-item Short-Form Health Survey.
SPADI = Shoulder Pain and Disability Index.
SRQ = Shoulder Rating Questionnaire.
SST = Simple Shoulder Test.
UCLA = University of California at Los Angeles Shoulder Rating Scale.
WHO = World Health Organization.
WORC = Western Ontario Rotator Cuff Index.
1. INTRODUCTION

This thesis is based on four papers that have been published in peer-reviewed journals or
are currently under review. Furthermore, some additional aspects are elaborated, such as
the definition of shoulder pain from a bio-psycho-social perspective and future trends within
the field of shoulder pain rehabilitation.

The main focus of this thesis is on patients with shoulder pain and the measures used in
assessment of the condition. Shoulder pain is a disabling condition that interferes
considerably with daily life. Despite this fact, little research has been carried out within a bio-
psycho-social context and few measures seem to have included a bio-psycho-social
viewpoint.

To investigate the disability in patients from a bio-psycho-social perspective, the International

Classification of Functioning, Disability and Health (ICF) can be used as a framework. The
ICF can also be used to provide an overview of the content in measures and thus provides
the ground for objective comparisons of different measures and/or patient experiences of
functioning. Further, it can be used as a basis for development of new measures. Despite its
potential, the ICF has been scarcely applied within the field of shoulder pain rehabilitation.

1.1 International Classification of Functioning, Disability and Health (ICF)

1.1.1 History and theoretical underpinnings

Collection of reliable information about the health of populations is one of the key roles of the
World Health Organization (WHO) [1]. To meet the demand for information and statistics
about non-fatal health outcomes, the WHO launched the International Classification of
Impairments, Disabilities and Handicaps (ICIDH) in 1980 [1]. The use of a language that
suggested a causal relationship between handicap, disability and impairment in the ICIDH
was heavily criticised. Due to this, there was no way the user was able to record whether an
improvement in the patients’ function was a result of rehabilitation or changes in the physical
or social environment. With the assistance of collaborating centres in Holland, France, North
America, and the Nordic countries, the WHO began the process of revising the ICIDH in
1993. A preliminary alpha draft was finalised for expert review by May 1996, and a second

1
beta draft was finalised and prepared for further field testing in 1997. As a result of the
revision, the International Classification of Functioning, Disability and Health (ICF) was
endorsed in May 2001 [2]. The ICF is currently a member of the WHO’s family of
classifications: The International Classification of Diseases (ICD) provides the codes for
mortality and morbidity whereas the ICF provides codes for the complete range of human
functioning and environmental factors [1, 3].

Although the need for a commonly agreed upon framework for functioning and disability is
widely acknowledged, the theoretical underpinnings of the ICF are debated [4]. First, bio-
psycho-social theory has been characterised as an integration of medicine into a holistic
framework; i.e., to include the psychosocial, without sacrificing the enormous advantages of
the biomedical approach [5]. However, the contribution of the bio-psycho-social perspective
in the development of disability theory has been scarce [4]. Second, the ICF states that the
presence of impairment does not indicate that a disease is necessarily present or that the
individual should be regarded as sick [2]. Disability is defined as interactions between
biology, personal factors and broader environmental constraints [4]. Nevertheless, at the
level of body functions and structures, the ICF defines impairment as a significant deviation
or loss from established statistical norms [2]. Thus, impairment according to the ICF is a pre-
social, biological and bodily difference. Third, the principle of universalism that was already
embodied in the ICIDH originates from the understanding that functioning and disablement
are understood as co-equal aspects of health, rather than polar opposites [6]. Universalism is
secured because the classifications of disablement are etiologically neutral. The principle of
universalism has been criticised by the social sciences because it implies the rejection of a
separate vocabulary, distinctive for a minority of people with a specific social status [6].

1.1.2 Conceptual framework and classification

The ICF consists of a conceptual framework and a classification [2]. The conceptual
framework consists of two parts, functioning and disability, and contextual factors.
Functioning and disability contains the components body functions and structures, and
activities and participation. Body functions are the physiological functions of body systems
(including psychological functions). Body structures are anatomical parts of the body, such
as organs, limbs and their components. Activities are the execution of tasks or actions by an
individual and participation is involvement in a life situation. The contextual factors consist of
the components environmental factors and personal factors. The environmental factors make
up the physical, social and attitudinal environment, in which people live and conduct their
lives. Personal factors are the particular background of an individual’s life and living. In the
ICF, individuals’ functioning in a domain is an interaction or complex relationship between the
2
health condition and contextual factors (Figure 1). The contextual factors interact with the
individual with a health condition and determine the level and extent of the individuals’
functioning.

Figure 1. Interactions between the components of the ICF

The ICF also contains a detailed classification of body functions and structures, activities and
participation and environmental factors, whereas personal factors are not classified. The
classification is organised in a hierarchical structure, with components, chapters and
categories [2]. Each category has a letter that refers to the component and a number
referring to the domain and level of precision. For example, combing ones hair is classified
by the third-level category caring for hair (d5202), belonging to the second-level caring for
body parts (d520) in the self-care chapter (d5) of the activities and participation component
(d). For the body functions, the letter that refers to the component is “b”, for body structures
“s” and for the environmental factors “e”. The structure of the ICF is generic, meaning that a
category is always derived from the overlying domain and components.

The ICF has an inbuilt five-point ordinal scale to rate the magnitude of functional problems or
influence of environmental factors [2]. The problems are denoted as impairments in body
functions and structures, activity limitations and participation restrictions. Environmental
3
factors are either barriers or facilitators of functioning. In addition, within activities and
participation, there is a distinction between performance which refers to what an individual
does in his or her current environment, and capacity, which is the maximum physiological
level of an individual in a standardised environment.

1.1.3 ICF Core Sets for specific conditions or settings

The full version of the generic ICF classification contains more than 1400 categories. To
improve its feasibility in clinical settings, identification of setting- or condition-specific
categories has been suggested as the first step [7]. To achieve this, specific linking rules
have been developed to transform information about functioning, into the ICF language [8, 9].
The most comprehensive overview of a condition or setting within the ICF framework is
provided with an ICF Core Set. An ICF Core Set is a list of ICF categories, usually at the
second level, that includes as few categories as possible to be practical, but as many as
necessary to describe the typical spectrum of problems in the functioning of patients with a
specific condition [10, 11]. The ICF Core Sets exist in a brief version for patients in a
particular clinical study and in a comprehensive version for multidisciplinary assessment in
clinical practice and research [10]. The development processes for an ICF Core Set is based
on four studies: a literature review of measures, a cross-sectional study with patient
interviews, a qualitative study with patient interviews and a global expert survey [10]. After
these initial studies, a consensus conference is conducted to decide which ICF categories
that should be implemented in the ICF Core Set. Based on these decisions, a tentative ICF
Core Set is presented. According to the WHO, the tentative ICF Core Sets need to be further
validated in clinical studies.

Since 2004, ICF Core Sets for musculoskeletal conditions have been developed. These are:
low back pain, osteoarthritis, osteoporosis, rheumatoid arthritis, chronic widespread pain and
ankylosing spondylitis [12-17]. A review that compared five of these musculoskeletal ICF
Core Sets indicated that they had a number of commonalities, although some particular
condition-specific differences were identified [18].

1.1.4 The Generic ICF Core Set

In a cross-sectional, multi-centre study, a generic ICF Core Set to describe and compare
functioning across health conditions was developed [19]. The generic ICF Core Set contains
the body functions energy and drive (b130), emotional functions (b152) and sensation of pain
(b280), and the activity and participation categories carrying out daily routine (d230), walking
(d450), moving around (d455) and remunerative employment (d850).

4
1.1.5 Application of the ICF in rehabilitation
Several attempts have been made to create an interface between the ICF and clinical
practice [20-22]. Content analyses of measures within the ICF framework have been
considered an important step in this work. Currently, content overviews of a number of
measures that commonly used in assessments of musculoskeletal conditions, are available
[8, 9, 23-26]. Content analyses of measures within the ICF framework provide useful
information for clinicians in the selection of measures and should enhance debates among
clinical experts and researchers [27-29].

In an on-going initiative from the Orthopaedic section of the American Physical Therapy
Association, evidence-based practice guidelines are developed for musculoskeletal
conditions commonly managed by physical therapists, such as adhesive capsulitis of the
shoulder, low back pain and neck pain [30-32]. In these guidelines, the ICF is used to classify
and define the conditions.

The WHO has advocated the joint use of the International Statistical Classification of
Diseases and Related Health Problems (ICD) and the ICF in rehabilitation [2, 3, 21]. The
main challenge has been the lack of alignment of concepts and terminology [33]. In the
current revision process of the ICD-10 that will be finished in 2015, so-called functional
properties are implemented within some health conditions [3, 34]. These functional properties
are reworded ICF categories for activities and participation that have been collected from the
WHO Disability Assessment Schedule 2.0, the World Health Survey, the condition- or
setting-specific ICF Core Set and the generic ICF Core Set [33].

In Norway, the Directorate of Health has taken the initiative to implement the ICF in the
health care system within certain fields [35, 36]. The Directorate has stated that future
implementation is dependent on further development and testing of the ICF Core Sets.

1.2 Shoulder pain

Shoulder pain is characterised by restricted and painful movement of the arm, which results
in difficulties in performing movement-related activities. In recent decades, research has
shown that psychological and social functioning may also be affected by shoulder pain;
additionally, environmental factors may contribute to the development or persistence of the
condition. The main focus of this section is to provide an overview of the current knowledge

5
about shoulder pain and how the condition affects functioning. In addition, the different types
of generic and condition-specific measures that are available are presented, within the
conceptual framework of the ICF.

1.2.1 Prevalence, incidence, clinical course and classification

The prevalence of shoulder pain in the general population was estimated to be 7 - 27% in
adults younger than 70 years and 13.2 - 26% for adults older than 70 in a previous review
[37]. The wide range of prevalence estimates was explained by differing definitions of the
condition in studies [37]. A more recent review on upper-extremity disorders, found that the
point prevalence estimates varied between 1.6 and 53% [38]. The authors of this review
warned that health professionals and policy makers should be aware of the lack of a
commonly agreed on method to measure the occurrence of the conditions in populations
[38].

The influence of different case-definitions for self-reported shoulder pain was demonstrated
in a study that looked at the prevalence of shoulder pain in general practice [39]. With a case
definition based on the question “during the past month, have you experienced pain in your
shoulder(s) lasting more than 24 hours?”, the prevalence was 51%. When the definition was
limited to current symptoms and at least one item in a disability questionnaire being
answered positively, the prevalence was restricted to 20% [39]. The authors suggested that
the latter case-definition excluded minor episodes of shoulder pain [39]. Few studies have
reported the incidence of shoulder pain; in the general population, it has been reported to be
0.9% for those aged 31 - 35 years, 2.5% for 42 - 46 years, 1.1% for 56 - 60 years, and 1.6%
for those aged 70 - 74 years [40].

According to gender differences, a study on musculoskeletal complaints in a Norwegian

county, found that 56.2% of the women and 36.5% of the men (n = 2740) reported shoulder
pain within the last 12 months [41]. In this study shoulder pain was the fourth most frequent
complaint after low back pain, neck pain and headache. [41]. The gender difference was
consistent with the findings in a Swedish study, in which the prevalence of self-reported
neck, shoulder and arm pain rose slightly, from 22.8 to 25.0% among females and from 12.8
to 15.4% among males over a 16 year period from 1990 to 2006 [42]. Interestingly, the
prevalence estimates peaked in 2002 and decreased between 2002 and 2006 [42]. The
authors, however, warned that it was too early to draw definite conclusions about a decrease
in prevalence of shoulder pain [42].

Many cases of shoulder pain are long-lasting; only one in five new episodes had resolved
completely six months later and half had not resolved after 18 months in a prospective cohort
6
study in primary care [43]. In another study in general practice, 41% of the patients
presenting symptoms of shoulder pain showed persistent symptoms after 12 months and
only 23% had recovered after 1 month [44].

The classification systems for shoulder pain have been criticised for being focused on
pathological findings, having overlapping diagnostic categories and for having conceptual
inconsistencies [45-50]. Because legitimate debate persists over the aetiology, pathogenesis,
anatomy and pathophysiology of shoulder pain, it has been suggested that recognition of
abnormal movement-patterns should be implemented in the classification systems of
shoulder pain [51, 52].

1.2.2 Subjective experiences of functioning

In the rehabilitation of patients with shoulder pain, the patient experiences of functioning are
considered vital. Patient-reported measures are often used as the primary outcome to
evaluate treatment interventions [45, 53]. To date, few studies have provided comprehensive
overviews of the disability associated with shoulder pain from the perspective of the patients.

In a cross-sectional study of the health status in 544 patients with five shoulder pain
diagnoses, self-reported health and functioning measured by the Medical Outcomes Study
36-item Short-Form Health Survey (SF-36) were compared with U.S. general population
norms [54]. Statistical differences were found according to physical functioning, role-physical,
bodily pain, social functioning, role-emotional, and the physical component summary score
[54]. In a register-study comprising 2674 patients with 16 common shoulder diagnoses,
substantial deficits in range of motion, muscle strength, activity performance and general
comfort were identified as the most common types of disability [55].

A number of studies have investigated limited aspects of the disability, such as mental
health, work and employment. In a community-based sample of 142 patients who had visited
their general practitioner with chronic shoulder pain, 69% reported that they slept less well
because of their shoulder, 54% had problems in carrying objects and 46% had problem
reaching for objects [56]. The predictive value of psychological factors was investigated in a
cohort study on 443 patients who consulted their general practitioner with neck or shoulder
pain and disability. Symptom characteristics, socio-demographic and psychological factors,
social support, physical activity, general health, and comorbidity were investigated at
baseline [57] . Less vitality, more worrying, duration of the symptoms before consulting the
general practitioner and a history of neck or shoulder symptoms were consistently associated
with poorer outcome of the condition after 3 and 12 months [57]. Another study on 587
primary care patients with new episodes of shoulder pain or low back pain, found that the
7
psychological factors were more strongly associated with persistent pain and disability after 3
months in patients with low back pain than in those with shoulder pain [58].

Shoulder pain is a common cause of work-absenteeism, accounting for approximately 18%

of the sick-leave benefit claims in Sweden [59]. In a Norwegian study on middle-aged
cohorts, participants were asked whether they had experienced any of 11 common health
problems in the past month, and whether they considered these to be work-related [60]. Of
the, 8594 (33%) that responded, pain in the neck/shoulders was the most frequently reported
complaint [60]. Approximately two-thirds reported that the neck/shoulder problem was work-
related [60]. Considerable research has been devoted to the identification of risk factors for
the development or maintenance of shoulder pain [61]. The effect of individual characteristics
and physical and psychosocial workplace factors on neck/shoulder pain was investigated in a
cross-sectional study on 3123 workers from 19 plants [62]. The strongest self-reported risk
factor was high job demands [62]. In a study on social support, job strain and
musculoskeletal pain among female health care personnel, symptoms in the shoulder and
neck were found to be significantly related to social support at work [63]. By contrast,
symptoms of low back pain were significantly related to job strain [63].

Shoulder pain seems to have been little investigated in qualitative studies. In a study on 24
patients with upper extremity disorders, participants were asked how they interpreted the
question “are you better?” [64]. Based on the qualitative analyses, the authors concluded that
the interpretation of functional recovery seemed to differ largely among individuals and in
some cases improvement did not seem to be linked to changes in the symptoms or function
[64].

Disability assessed with patient-reported measures has been found to be higher in subjects
with additional diseases or symptoms that cause discomfort in the chest region [65]. Two
other studies found that additional pain or symptoms in other body regions were predictive
for higher disability levels among the patients [66, 67].

1.2.3 Assessment of body functions and structures

In the ICF, body functions and structures are the physiological functions (including
psychological functions) and the anatomical parts of the body [2]. The component covers
chapters such as pain, neuromuscular and movement-related functions and mental health.

Traditionally, the physical examinations of movement-related functions and pain intensity

have been a cornerstone in assessment of patients with shoulder pain [25, 68-70]. A number
of condition-specific single-item measures (physical examination tests) are used in the

8
clinical decision-making [69, 70]. In addition to these tests, the physical examination of
patients is covered by the content of condition-specific multi-item measures that either
contain a combination of physical examination sections and patient-reported sections
(composite scales) or are completely patient-reported [45, 68, 71].

The aim of treatment interventions in patients with shoulder pain often is to restore
movement patterns in the upper extremities [72-74]. Within the field of shoulder pain, there
are few clinical measures available that cover observation of movement patterns. In research
laboratories, movement patterns have been studied by electromyography [75-81].

In the ICF, mental health functions are classified within body functions. Sleeping problems
are common among patients with shoulder pain, and items referring to sleep are integrated in
several condition-specific measures [26, 55, 68]. It is a matter of controversy whether the
other aspects of mental health or general health should be incorporated in assessment of
shoulder pain [82, 83].

The structural deficits in the shoulder-joint area have historically been a major clinical
research focus. Ruptures in the supraspinatus tendon were first described in a study from
1834 and several later studies from the early days of modern orthopaedic surgery [84, 85]. In
current practice, structural deficits are investigated with plain radiography, magnetic
resonance imaging, ultrasonography and direct clinical or surgical observations [86]. The
interpretation of structural impairments with respect to functioning is controversial and it has
been outlined that it is imperative that magnetic resonance imaging is only used with clear
indications and when the results are expected to alter the clinical management [87].

1.2.4 Assessment of activities and participation

Activities are the execution of a task or action by an individual and participation is
involvement in a life situation [2]. The component covers domains such as mobility, self-care,
interpersonal interactions/relationship, employment and leisure activities.

In assessment of shoulder pain, limitations or restrictions in activities and participation are

often covered by patient-reported sections in the condition-specific multi-item measures [25,
26]. It has been a source of controversy among researchers and clinical experts, whether the
content of these measures should be targeted to movement functions and pain, or
incorporate general aspects of functioning [82, 88, 89]. Although the measurement properties
of these measures have been extensively reviewed, scarce attention has been paid to the
content of the measures [90-95].

9
Concepts referring to working performance are often incorporated in condition-specific
measures [59, 60]. While some of the measures only address work in a single item, others
provide complete sections on work [68, 96]. In addition, concepts reflecting interpersonal
interactions/relationships was identified in the content of a condition-specific multi-item
measure that was linked to the ICF [26]. Due to the significant disability associated with
shoulder pain, a combination of condition-specific and generic measures of general health
have been recommended for the assessments [54, 55, 97, 98]. Previously published content
analyses of the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36) and five
other general health measures, show that much of their content cover the activities and
participation component of the ICF [23].

Emerging evidence indicates that clinician-rated measures cover different constructs than the
patient-reported measures [99-103]. The need for clinician-rated measures that cover activity
limitations in patients with shoulder pain has been advocated [25].

1.2.5 Assessment of environmental factors

The environmental factors of the ICF cover products, technology, social support/relationships
and attitudes [2]. According to the ICF, the environmental factors are potential facilitators or
barriers of functioning [2]. The shoulder pain rehabilitation research has mostly been devoted
to the identification of risk factors in the working environment [61, 62, 104-111]. Based on
this scarce research, we did not expect that concepts reflecting environmental factors were
frequent in measures used for assessment of shoulder pain.

2. AIMS OF THE PROJECT

The purpose of this thesis was to present a comprehensive picture of shoulder pain within
the ICF framework, to investigate the correspondence between the patient experiences of
functioning and the content of measures and to develop and test a clinician-rated measure.

In more detail, the specific aims were to:

x Identify the most frequently addressed ICF categories in measures used for assessments
of patients with shoulder pain (Paper I).

10
x Identify the ICF categories that reflects problems related to functioning and interactions
with the environment in patients with shoulder pain (Paper II).
x Investigate how the content of measures used in assessments of shoulder pain
corresponds with the patient experiences of functioning (Paper III).
x Present a preliminary list of ICF categories for shoulder pain, covering the patient
experiences and the concepts included in frequently used measures (Thesis).
x Develop and test the reliability and ability to detect change over time, of a clinician-rated
activity measure of the shoulder, based on the assessment of movement patterns (Paper
IV).

3. MATERIAL AND METHODS

3.1 Design

The present work was based on a literature review and two clinical studies that comprised
patients with shoulder pain. In the literature review, the measures used in the assessment of
shoulder pain were identified and analysed according to their content (Paper I). The first
clinical study, a cross-sectional study with patient interviews (Paper II), was conducted in
parallel with the literature review. The other clinical study was a study with a test-retest
design that was used to develop and test the reliability of a clinician-rated activity measure
(Paper IV). In addition, the datasets from the literature review and the cross-sectional study
constituted the material that was used in the comparison of the patient experiences and the
content of measures (Paper III) and in the development of a preliminary list of ICF categories
for shoulder pain (Thesis).

3.2 Subjects

Patients with shoulder pain were the focus in all three studies. In the literature review (Paper
I) the aim was to analyse the content of measures used in clinical studies on patients with

11
shoulder pain, aged 18 years or older. Articles written in English and published in peer-
reviewed journals between January 2005 and May 2010 were included. The exclusion
criteria were: studies on patients with fractures, joint replacement, complete dislocation,
malignant condition, rheumatic diagnosis and stroke. In addition to these subject criteria,
quantitative studies with less than 31 participants were excluded.

The participants in the cross-sectional study (Paper II) were patients attending the outpatient
clinic of the Department of Physical medicine and Rehabilitation at Oslo University Hospital,
Ullevaal from November 2009 through February 2011. Patients aged 18 years and older,
diagnosed with shoulder pain with symptoms lasting longer than 3 months were eligible for
the study. The exclusion criteria were similar to those in the literature review. In addition,
patients with a generalised pain condition and insufficient Norwegian language skills were
excluded

The subjects in the test-retest study (Paper IV) were patients attending the Department of
Physiotherapy at the Martina Hansen Hospital in Baerum, between December 2007 and
October 2010. Patients aged 18 years or older diagnosed with subacromial impingement
syndrome were included. The exclusion criteria were systematic inflammatory disease or
generalised pain, cardiac disease, symptoms of cervical spine disease or surgery in the
affected shoulder within the last six months.

The collection of data from the patients was based on approval from the Ethical Committee
for Medical Research and all patients gave their informed consent.

3.3 Material

This section describes the search procedure for the literature review of measures (Paper I),
the collection of data from the patient interviews (Paper II) and the development process of a
clinician-rated activity measure (Paper IV).

3.3.1 Literature review of measures

For the literature review of measures, a highly sensitive 15-step search strategy for Medline
was developed and adapted to Embase, PeDro, Cinahl and Central [112]. The retrieved
articles were imported to the same Endnote library (version X3, Thomson Reuters 1500
Spring Garden Street, Philadelphia) and screened for duplicates. In cases of multiple

12
publications, the journal with the highest impact factor was selected. All remaining articles
were imported into a Microsoft Access database (Microsoft Office 2003) for the abstract
screening. Articles meeting any exclusion criteria were excluded. In cases in which the
decision was to include the article or the exclusion decision was ambiguous, full versions of
the articles were retrieved. All abstracts were screened by one reviewer; a random selection
of 20% was also screened by a second reviewer before a final decision was made. Measures
with only one item, for example clinical tests and technical examinations were labelled single-
item measures, whereas measures that contained more than one item, for example patient-
reported outcome measures or composite scales were labelled as multi-item measures. A
total of 13511 articles were identified through the literature search; of these articles, 1591 full
versions were screened, and 515 were included.

To investigate whether any recent changes had taken place in the types of multi-item
measures applied in clinical studies, an additional literature search in Medline for studies
published during the last year (August 2012 - July 2013) was conducted. The same search
strategy and inclusion/exclusion criteria as in the literature review (Paper I) was applied. In
this updated literature search a total of 1538 articles were retrieved. Of these 1396 were
excluded and 142 were included for further analysis. The screening and analysis in this
updated review were based on the abstracts of the articles and was conducted by one
reviewer (YR).

3.3.2 Patient interviews

In the cross-sectional study with patient interviews (Paper II), an Extended ICF Checklist was
derived from the ICF classification. This checklist was a condition-adapted version of the
generic ICF Checklist Version 2.1a [113]. To ensure that the most relevant functions were
covered, physical examination tests and condition-specific scales were identified in published
reviews and linked to ICF categories by one researcher (Y.R.) [8, 9, 69, 92]. A total of 9
physical examination tests and 10 condition-specific scales were identified. From the linked
content of these measures, 23 additional second-level ICF categories were added to the 123
categories in the generic checklist. Thus, the Extended ICF Checklist applied in the present
study consisted of 146 second level ICF categories (Appendix 1). Of these ICF categories,
52 were from the component body functions and structures, 57 from activities and
participation and 37 from environmental factors. The patients’ problems in each category
were rated on an ordinal scale with scores ranging from 0 to 4 [2]. For the body functions
components, the scores included “no impairment”, “mild impairment”, “moderate impairment”,
“severe impairment” and “complete impairment”. For the body structures component, only the
presence of impairment was rated as “impairment” or “no impairment” in this study. In the
13
activities and participation component, the categories were denominated “no difficulty”, “mild
difficulty”, “moderate difficulty”, “severe difficulty” and “complete difficulty”, and the ratings
were made according to reported performance. The environmental factors component
included both barriers and facilitators of functioning, each categorised as “mild”, “moderate”,
“severe” or “complete”. Additional options on the ICF qualifiers scale were “not specified”
(score 8) and “not applicable” (score 9). The “not specified” option was avoided, and the “not
applicable” was only registered for mutually exclusive categories in the major life areas
chapter (d8) in the ICF. Comorbidity was registered on a separate form. The included
patients participated in a structured interview using the Extended ICF Checklist. All of the
interviews were administered by the same person (YR), a physiotherapist and researcher
who had extensive experience with the ICF and shoulder rehabilitation in clinical and
educational settings. The ratings of the severity of functional problems in the Extended ICF
Checklist were determined through a discussion with the patient.

In addition to the patient interviews, the patients completed the Shoulder Pain and Disability
Index (SPADI) and the Self-Administered Comorbidity Questionnaire (SCQ) [114-116]. The
SPADI is a patient-reported condition-specific instrument comprising 13 items assessing pain
and problems in functioning. Ratings are registered on an eleven point ordinal scale from “no
pain/no difficulty” (0) to “worst pain imaginable/so difficult that help is required” (10). A sum
score ranging 0 - 100 (best - worst) is estimated by averaging the pain and disability sub-
scores. The SCQ is a patient-rated instrument with a list of common health problems. An
additional question on neck pain was added. The respondent is asked to mark whether the
health problem is present, whether treatment has been received and whether the problem
limits activities.

3.3.3 Development of a clinician-rated activity measure

The aim of Paper IV was to develop and test the reliability and ability to detect change over
time, of a clinician-rated activity measure of the shoulder. The steps in the development
consisted of the identification of eligible items, followed by pilot-testing, clinical testing and
scale construction [117-119]. The eligible items were extracted from patient-reported
condition-specific scales that had been reviewed [91, 92, 95]. From these scales, 21 items
that covered the execution of tasks with dynamic movements of the arm at or above
shoulder-level were identified. These patient-reported items were then adapted to a
standardised test environment. Some of the items required substantial adaptions; for
example, a test rig with a light fixture was constructed to test difficulties in screwing a light
bulb. Based on this pilot testing, 14 items that were difficult to standardise, or gave little
information about the patient’s movement patterns were excluded. Decisions about exclusion
14
were based on consensus between the researchers. The remaining 7 items were included in
a clinical test-retest study.

To rate the magnitude of a functional problem, a five-point ordinal scale was applied [2]. The
anchor-points of the scale were denoted “no difficulty”, “mild difficulty”, “moderate difficulty”,
“severe difficulty” and “cannot perform”. No definition of “difficulty” was provided due to the
assumption that experienced physical therapists in shoulder rehabilitation have a common
understanding of the term.

3.4 Analyses

3.4.1 Content analyses

In the literature review of measures (Paper I), generic and condition-specific measures with a
single or multiple items, were extracted from the articles. The meaningful concepts in the
measures were linked to the most specific ICF category possible, according to the linking-
rules [8, 9]. All measures were linked by one reviewer (YR) and a random selection of 25% of
the multi-item measures was also linked by a second reviewer. The ICF links of ten
measures that had already been published in scientific journals or were available in previous
reviews from the ICF Research Branch were directly applied in the analyses [23, 26].

The analyses of the correspondence between the patient experiences of functioning and the
content of measures (Paper III) was based on the datasets from the literature review of
measures and the cross-sectional study with patient interviews. The following criteria were
applied for the analyses: (1) categories included in both datasets with similar rankings, (2)
categories included in both datasets with different rankings, and (3) categories included in
only one of the datasets. To investigate the match between common patient-reported
problems and the content of condition-specific measures, the high-frequency ICF categories
from the cross-sectional study (reported by ≥ 50%) were compared with the linked content of
the most frequently cited condition-specific multi-item measures (identified with ≥ 10
citations).

For the identification of a preliminary list of ICF categories for shoulder pain (Thesis), the
datasets from the literature review of measures and the cross-sectional study with patient
interviews were merged and organised according to the ICF structure.

15
In the development process of the clinician-rated activity measure (Paper IV), the items and
the intention of the scale were linked to the ICF by two independent reviewers [8, 9].

3.4.2 Statistical analyses

In the literature review of measures (Paper I), the number of retrieved articles, single/multi-
item measures and meaningful concepts, are presented with descriptive statistics. The
abstract screening and linking procedures were measured by percentage agreement and the
estimation of Cohen’s Kappa coefficient. The 95% confidence intervals for the Kappa
coefficient were constructed using the bias-corrected percentile method [120, 121]. A Kappa
coefficient of 0 - 0.40 was considered poor, 0.41 - 0.60 fair to good and 0.61 - 1 excellent
[122]. The agreement between the reviewers in the abstract screening was 87.3%. The
estimated Kappa coefficient was 0.62 (95% CI, 0.59 - 0.66), which is considered good. For
the linking procedure, the agreement was 80.8%. The estimated Kappa coefficient was 0.81
(95% CI, 0.77 - 0.85), which is considered excellent. The relative frequencies of the identified
ICF categories were calculated from the number of times the concept referring to the item
was cited, divided by the total number of citations (n = 2469). The ICF categories that
emerged with a frequency of at least 1% were reported in descending order, for each ICF
component separately. In addition, an overview at ICF chapter-level of the content of
measures that emerged with more than 5 citations was provided.

In the cross-sectional study with patient interviews (Paper II) the patients’ age in years were
calculated with the mean and Standard Deviation (SD). Frequencies were used for
descriptive statistics concerning gender and employment status. The SPADI total summary
score was estimated with the mean (SD). The relative frequencies (%) of ICF categories
registered as impairment, limitation, restriction, barrier or facilitator for at least 5% of the
participants were reported in descending order, for each ICF component separately.

In the test-retest study (Paper IV), age in years, duration of pain in month and the SPADI
total summary score were calculated with the mean (SD). To reduce the number of items,
item-to-sum correlation with Pearson’s product-moment correlation coefficient (r) was used
as the main criterion. In the remaining items, reliability, defined as internal consistency,
reliability and measurement error were estimated according to recent recommendations [123,
124]. The internal consistency was calculated with Cronbach’s alpha, and an alpha between
0.7 and 0.9 was considered fair. The consistency of the scale was investigated with inter-
item correlations, based on the Pearson’s product-moment correlation coefficient [125]. Inter-
item correlations in the range of 0.15 - 0.50, and mean inter-item correlations of 0.40 - 0.50
were considered acceptable [117]. The inter-rater reliability and test-retest reliability was

16
calculated from a two-way random effect model and reported with the Intraclass Correlation
Coefficient (ICC) and a 95% Confidence Interval (CI) [126, 127]. The measurement error was
defined as the systematic and random error of a patient’s score that was not attributed to true
changes in the construct to be measured [123]. The calculation of measurement error was
based on the Standard Error of Measurement (SEM), which reflects the standard deviation of
the distribution of the patient’s score, with no change in health status and no learning effect
taking place [128, 129]. To take the systematic difference into account, the calculation was
based on the following formula: ܵ‫ܯܧ‬௔௚௥௘௘௠௘௡௧  = ߪ௫ ඥͳ െ ‫ݎ‬௧௧ , where ( ߪ௫ ) is the pooled
standard deviation of the test and retest scores, and (‫ݎ‬௧௧ ) is the reliability coefficient. From the
SEM value, it is possible to estimate the Minimal Detectable Change (MDC), which is the
smallest change that can be defined by the instrument beyond the measurement error [130,
131]. The following formula was applied: ‫ ܥܦܯ‬ൌ ͳǤͻ͸ ൈ ξʹ  ൈ ܵ‫ܯܧ‬, where 2 relates to the
test and retest, and 1.96 relates to the 95% confidence interval.

All the statistical analyses were conducted with the IBM SPSS Statistics 19 and 20 for
Windows, or Stata/IC 11.1 for Mac.

4. MAIN RESULTS

4.1 Literature review of measures (Paper I)

In the literature review of measures (Paper I), altogether 475 different measures were
extracted with a total of 2469 citations. Among them, 370 were single-item measures and
105 were multi-item measures. In all 20517 meaningful concepts were extracted from the
measures, of which 86.3% were linked to the ICF. The share of concepts that were not
covered or not definable was 13.7%.

A total of 40 second-level ICF categories with a frequency above 1% were identified in the
ICF components of body functions and structures, activities and participation and
environmental factors. Among the 11 ICF categories that were identified within body
functions and structures, 5 categories were located in the neuromusculoskeletal or
movement related functions (b7) chapter, 3 in mental functions (b1), 2 in sensory functions

17
and pain (b2) and 1 in structures related to movements (s7). The highest ranked categories
of body functions and structures were in descending order: sensation of pain (b280), mobility
of joint functions (b710), structure of shoulder region (s720), muscle power functions (b730),
sleep functions (b134), stability of joint functions (b715) and emotional functions (b152).

Within activities and participation, 28 ICF categories were identified. Of these, 9 belonged to
the mobility chapter (d4), 6 to self-care (d5), 4 to domestic life (d6), 3 to interpersonal
interactions and relationships (d7) and major life areas (d8), and 1 category each to the
chapters of community, social and civic life (d9), learning and applying knowledge (d1) and
general tasks and demands (d2). The highest ranked ICF categories within activities and
participation were in descending order: hand and arm use (d445), remunerative employment
(d850), recreation and leisure (d920), lifting and carrying objects (d430), washing oneself
(d510), dressing (d540), caring for body parts (d520), doing housework (d640) and
maintaining a body position (d415).

In the component of environmental factors, the only identified ICF category was products or
substances for personal consumption (e110). This category belongs to the products and
technology (e1) chapter.

Of the 105 multi-item measures, 16 condition-specific and 7 generic measures had 5 or more
citations. By far the most cited was the Constant-Murley Shoulder Score (Constant) (124
citations) [68], followed by the American Shoulder and Elbow Surgeons Standardized Form
for Assessment of the Shoulder (ASES) (77 citations) [71], the University of California at Los
Angeles Shoulder Rating Scale (UCLA) (64 citations) [132] and the Disability of the Arm,
Shoulder and Hand (DASH) scale (51 citations) [96]. Of these condition-specific multi-item
measures, the DASH and the ASES were the most wide-ranging, containing concepts linked
to categories in 11 and 9 ICF chapters, respectively. In contrast, the Constant and the Rating
Sheet for Bankart Repair (Rowe) contained concepts linked to 4 and 2 ICF chapters,
respectively [68, 133]. None of these most cited measures covered mental functions other
than sleep (b134), and the UCLA (the third most cited) did not cover any mental functions.
The most-frequently cited generic measure, the Medical Outcomes Study 36-item Short-
Form Health Survey (SF-36) (46 citations), was linked to 7 ICF-chapters; 2 of which were in
the body functions and structures component, and 5 of which were in the activities and
participation component [134].

In the updated literature search on Medline that investigated measures extracted from
articles published in the last year, a total of 24 different condition-specific measures were
identified in 148 citations. The measures that were registered with 5 or more citations were in
18
descending order: Constant (31 citations), ASES (25 citations), DASH (18 citations), the
Simple Shoulder Test (SST) (9 citations), Rowe (8 citations) and the Western Ontario Rotator
Cuff Index (WORC) (5 citations). The SF-36 and the Shoulder Pain and Disability Index
(SPADI) received only 4 and 3 citations, respectively.

Of the 370 single-item measures that were extracted in the literature review, 28 condition-
specific and 7 generic measures had five or more citations. Patient-reported pain intensity
was the most frequently cited (200 citations) followed by active range of motion (170
citations), magnetic resonance imaging (125 citations), muscle strength (98 citations), x-ray
(81 citations), passive range of motion (61 citations) and ultrasonography (57 citations). The
content of the single-item measures covered 3 body functions and structures chapters; these
were sensory functions and pain (b2), neuromusculoskeletal or movement related functions
(b7) and structures related to movements (s7).

4.2 Patient interviews (Paper II)

In the cross-sectional study with patient interviews (Paper II), 375 patients received
information about the study, and 165 (44%) were included. The mean age of the participants
was 46.5 years (SD = 12.5). Women were slightly over-represented in the study sample
(54%). The diagnosis of shoulder impingement syndrome was the most frequent, accounting
for 43% of the cases. With regard to employment status, 92.8% of the participants were
employed or students, of whom 35.2% were on sick leave. The rest of the participants (7.2%)
were retired, unemployed, received a disability pension, or were homemakers. The SPADI
total summary score was 47.4 (SD = 21.1). Additional neck pain was reported by almost two-
thirds and low back pain by more than one-third of the patients.

A total of 61 second-level ICF categories were identified from the patient interviews. Of the
19 body functions and structures categories that were identified, 7 each belonged to the
mental functions (b1) and neuromuscular and movement-related functions (b7) chapters, 3 to
structures related to movements (s7) and 1 each to sensory functions and pain (b2) and
functions of the skin and related structures (b8). The 11 high-frequency (> 50%) body
functions and structures categories that were identified were in descending order: sensation
of pain (b280), structure of shoulder region (s720), mobility of joint functions (b710), sleep
(b134), muscle endurance functions (b740), energy and drive functions (b130), muscle

19
power functions (b730), mobility of bones function (b720), sensation related to the skin
(b840), muscle tone functions (b735) and temperament and personality functions (b126).

With respect to problems in the activities and participation, 34 ICF categories were identified;
of these 10 were in the mobility (d4) chapter, 7 in interpersonal interactions and relationships
(d7), 5 each in self-care (d5) and domestic life (d6), 3 in general tasks and demands (d2), 2
in major life areas (d8) and 1 each in learning and applying knowledge (d1) and community
and social and civic life (d9). The 9 high-frequency (> 50%) activity and participation
categories that were identified were in descending order: lifting and carrying objects (d430),
remunerative employment (d850), recreation and leisure (d920), changing basic body
positions (d410), washing oneself (d510), dressing (d540), maintaining a body position
(d415), doing housework (d640) and acquisition of goods and services (d620).

Within the environmental factors, 8 ICF categories were identified; of these, 5 belonged to
the support and relationship (e3) chapter. None of the environmental factor categories were
high-frequency. With the exception of products and technology for communication (e125), all
the environmental categories covered various aspects of social support and services;
support from family (e310), friends (e320), colleagues and others (e325), persons in
positions of authority (e330) and health professionals (e355) and also their individual
attitudes (e450) and the social security services (e570). The environmental social support
from immediate family and friends (e310 and e320 ICF categories) were, in a majority of
cases, reported facilitators of functioning.

4.3 Patient experiences in relation to the content of measures (Paper III)

The two separate datasets of ICF categories from the cross-sectional study with patient
interviews and the literature review of measures constituted the material that was used to
compare the patient experiences in relation to the content of measures (Paper III). The ICF
category higher education (d830) was not included in the analyses because the relative
frequency had not been calculated for this category. The total number of high frequency (≥
50%) ICF categories from the patient interviews were 20; of these, 11 were in body functions
and structures and 9 were in activities and participation.

A total of 21 different ICF categories of body functions and structures were identified either in
the patient interviews or the literature review of measures. Almost all of them (19 categories)

20
were identified in the patient interviews, and approximately half (11 categories) were
identified in the measures. Of the 11 patient-derived body functions and structures categories
that were high-frequency, 7 also attained a high ranking in the measures. In descending
order, these common and high-ranked categories were sensation of pain (b280), structure of
shoulder region (s720), mobility of joint functions (b710), sleep functions (b134), energy and
drive functions (b130), muscle power functions (b730) and mobility of bone functions (b720).
Four other high-frequency patient-derived categories; muscle endurance (b740), muscle tone
(b735), sensation related to the skin (b840), and temperament and personality functions
(b126) and also several lower-frequency patient-derived categories were not identified in the
measures. Only 2 lower ranked ICF categories were uniquely identified in the measures.

Within activities and participation, 32 ICF categories were derived from the patient interviews
and 28 from the measures. All 9 of the high frequent patient-derived categories were also
identified in the content of the measures. In descending order, these common and high-
frequency categories were lifting and carrying objects (d430), remunerative employment
(d850), recreation and leisure (d920), changing basic body position (d410), washing oneself
(d510), dressing (d540), maintaining a body position (d415), doing housework (d640) and
acquisition of goods and services (d620). Among the 9 low frequency, patient-derived
categories that were not identified in the measures, 3 categories concerned various aspects
of interpersonal interactions and relationships. Four ICF categories were uniquely identified
in the literature review of measures (rank 18 – 24).

With respect to the environmental factors, 8 ICF categories were derived from the patient
interviews. None of these were high-frequency or identified in the measures. With the
exception of products and technology for communication (e125), all the environmental
categories covered various aspects of social support and services. The only category that
was derived from the measures, products or substances for personal consumption (e110),
covers the use of pain medication.

The 11 condition-specific multi-item measures that were identified with at least 10 citations in
the literature review of measures are compared with the 20 high-frequency (≥ 50%) patient-
derived body functions and structures and activities and participation categories in Table 1.
These commonly used condition-specific measures were: the Constant [68], the ASES [71],
the UCLA [132], the DASH [96], the SST [135], the SPADI [115], the Rowe [133], the WORC
[136], the SRQ [137], the SDQ [138] and the OSS [88]. Of these measures, the Constant,
ASES, UCLA and Rowe are composite scales whereas the rest are entirely patient-reported
scales. The investigation of how these commonly used condition-specific measures match
the high-frequency patient-derived categories displays that 6 ICF categories are not included
21
in any of the measures, these are the 5 body functions temperament and personality (b126),
energy and drive (b130), muscle tone (b735), muscle endurance (b740), sensation related to
the skin (b840), and in addition the activity changing basic body position (d410). The two
most comprehensive measures, the ASES and the DASH, match 11 and 10 of these high
frequent patient-derived ICF categories, respectively. By contrast, the SST, SPADI, SDQ and
the Rowe match the lowest number of categories (n = 5), while the most cited measure, the
Constant, matches 6 high-frequency patient-derived categories.

Table 1. Distribution of high frequency second-level ICF categories (n = 20) derived from the
patient interviews within the most frequently cited condition-specific measures of shoulder
function (n = 11)

Body functions and structures Activities and participation

Acquisition of goods and services (d620)

Temperament and personality (b126 )

Changing basic body position (d410)

Sensation related to the skin (b840)

Maintaining a body position (d415)

Structure of shoulder region (s720)

Remunerative employment (d850)

Lifting and carrying objects (d430)

Recreation and leisure (d920)

Muscle endurance (b740)
Mobility of bones (b720)

Doing housework (d640)

Sensation of pain (b280)
Energy and drive (b130)

Washing oneself (d510)

Mobility of joint (b710)

Muscle power (b730)

Number of citations

Muscle tone (b735)

Dressing (d540)
Sleep (b134)

Measures
Constant 124 √ √ √ √ √ √
ASES 77 √ √ √ √ √ √ √ √ √ √ √
UCLA 64 √ √ √ √ √ √ √
DASH 51 √ √ √ √ √ √ √ √ √ √
SST 46 √ √ √ √ √
SPADI 31 √ √ √ √ √
Rowe 31 √ √ √ √ √
WORC 21 √ √ √ √ √ √
SRQ 15 √ √ √ √ √ √ √ √
SDQ 14 √ √ √ √ √
OSS 11 √ √ √ √ √ √ √ √
Constant = the Constant-Murley shoulder score, ASES = the American Shoulder and Elbow Surgeons
standardized form for assessment of the shoulder, UCLA = the University of California at Los Angeles Shoulder
Rating Scale, DASH = the Disability of the Arm, Shoulder and Hand scale, SST = the Simple Shoulder Test, SPADI
= the Shoulder Pain and Disability Index, Rowe = a Rating Sheet for Bankart Repair, WORC = the Western
Ontario Rotator Cuff Index, SRQ = the Shoulder Rating Questionnaire, SDQ the Shoulder Disability
Questionnaire, OSS = the Oxford Shoulder Score.

22
4.4 A preliminary list of ICF categories for shoulder pain (Thesis)

The categories that were identified in the cross-sectional study with patient interviews and
the literature review of measures, constitute a preliminary list of 68 ICF categories for
shoulder pain (Thesis). Of these, 21 categories are body functions and structures, 38 are
activities and participation and 9 are environmental factors. Thirty-three of the categories
were identified in both studies; whereas 28 were identified only in the patient interviews and
7 only in the literature review of measures. The preliminary list of ICF categories for shoulder
pain with the definition of each category is presented in Table 2.

Table 2. Preliminary list of condition-specific ICF categories for shoulder pain covering body
functions and structures, activities and participation and environmental factors.

BODY FUNCTIONS
= the physiological functions of body systems (including psychological functions).
b126 Temperament and personality functions
General mental functions of constitutional disposition of the individual to react in a particular
way to situations, including the set of mental characteristics that makes the individual distinct
from others.
Inclusions: functions of extraversion, introversion, agreeableness, conscientiousness, psychic
and emotional stability, and openness to experience; optimism; novelty seeking; confidence;
trustworthiness.
b130 Energy and drive functions
General mental functions of physiological and psychological mechanisms that cause the
individual to move towards satisfying specific needs and general goals in a persistent manner.
Inclusions: functions of energy level, motivation, appetite, craving (including craving for
substances that can be abused), and impulse control.
b134 Sleep functions
General mental functions of periodic, reversible and selective physical and mental
disengagement from one’s immediate environment accompanied by characteristic
physiological changes.
Inclusions: functions of amount of sleeping, and onset, maintenance and quality of sleep;
functions involving the sleep cycle, such as in insomnia, hypersomnia and narcolepsy.
b140 Attention functions
Specific mental functions of focusing on an external stimulus or internal experience for the
required period of time.
Inclusions: functions of sustaining attention, shifting attention, dividing attention, sharing
attention; concentration; distractibility.
b144 Memory functions
Specific mental functions of registering and storing information and retrieving it as needed.
Inclusions: functions of short-term and long-term memory, immediate, recent and remote
memory; memory span; retrieval of memory; remembering; functions used in recalling and
learning, such as in
nominal, selective and dissociative amnesia.
b152 Emotional functions
Specific mental functions related to the feeling and affective components of the processes of
the mind.
Inclusions: functions of appropriateness of emotion, regulation and range of emotion; affect;
23
 sadness, happiness, love, fear, anger, hate, tension, anxiety, joy, sorrow; lability of emotion;
flattening of affect.
b164 Higher level cognitive functions
Specific mental functions especially dependent on the frontal lobes of the brain, including
complex goal-directed behaviors such as decision-making, abstract thinking, planning and
carrying out plans, mental flexibility, and deciding which behaviors are appropriate under what
circumstances; often called executive functions.
Inclusions: functions of abstraction and organization of ideas; time management, insight and
judgment; concept formation, categorization and cognitive flexibility.
b265 Touch function
Sensory functions of sensing surfaces and their texture or quality.
Inclusions: functions of touching, feeling of touch; impairments such as numbness,
anaesthesia, tingling, paraesthesia and hyperaesthesia.
b280 Sensation of pain
Sensation of unpleasant feeling indicating potential or actual damage to some body structure.
Inclusions: sensations of generalized or localized pain, in one or more body part, pain in a
dermatome, stabbing pain, burning pain, dull pain, aching pain; impairments such as myalgia,
analgesia and hyperalgesia.
b710 Mobility of joint functions
Functions of the range and ease of movement of a joint.
Inclusions: functions of mobility of single or several joints, vertebral, shoulder, elbow, wrist, hip,
knee, ankle, small joints of hands and feet; mobility of joints generalized; impairments such as
in hypermobility of joints, frozen joints, frozen shoulder, arthritis.
b715 Stability of joint functions
Functions of the maintenance of structural integrity of the joints.
Inclusions: functions of the stability of a single joint, several joints, and joints generalized
impairments such as in unstable shoulder joint, dislocation of a joint, dislocation of shoulder and
hip.
b720 Mobility of bones function
Functions of the range and ease of movement of the scapula, pelvis, carpal and tarsal bones.
Inclusions: impairments such as frozen scapula and frozen pelvis.
b730 Muscle power functions
Functions related to the force generated by the contraction of a muscle or muscle groups.
Inclusions: functions associated with the power of specific muscles and muscle groups,
muscles of one limb, one side of the body, the lower half of the body, all limbs, the trunk and
the body as a whole; impairments such as weakness of small muscles in feet and hands,
muscle paresis, muscle paralysis, monoplegia, hemiplegia, paraplegia, quadriplegia and
akinetic mutism.
b735 Muscle tone functions
Functions related to the tension present in the resting muscles and the resistance offered when
trying to move the muscles passively.
Inclusions: functions associated with the tension of isolated muscles and muscle groups,
muscles of one limb, one side of the body and the lower half of the body, muscles of all limbs,
muscles of the trunk, and all muscles of the body; impairments such as hypotonia, hypertonia
and muscle spasticity.
b740 Muscle endurance functions
Functions related to sustaining muscle contraction for the required period of time.
Inclusions: functions associated with sustaining muscle contraction for isolated muscles and
muscle groups, and all muscles of the body; impairments such as in myasthenia gravis.
b770 Gait pattern functions
Functions of movement patterns associated with walking, running or other whole body
movements.
Inclusions: walking patterns and running patterns; impairments such as spastic gait, hemiplegic
gait, paraplegic gait, asymmetric gait, limping and stiff gait pattern.
b780 Sensations related to muscles and movement
Sensations associated with the muscles or muscle groups of the body and their movement.
Inclusions: sensations of muscle stiffness and tightness of muscles, muscle spasm or
constriction, and heaviness of muscles.
b840 Sensation related to the skin
24
BODY STRUCTURES
= anatomical parts of the body such as organs, limbs and their components.
s710 Structure of head and neck region
s720 Structure of shoulder region
s730 Structure of upper extremity

ACTIVITIES AND PARTICIPATION

= the execution of a task or action by an individual or involvement in a life situation.
d170 Writing
Using or producing symbols or language to convey information, such as producing a written
record of events or ideas or drafting a letter.
d210 Undertaking a single task
Carrying out simple or complex and coordinated actions related to the mental and physical
components of a single task, such as initiating a task, organizing time, space and materials for
a task, pacing task performance, and carrying out, completing, and sustaining a task.
Inclusions: undertaking a simple or complex task; undertaking a single task independently or in
a group.
d220 Undertaking multiple tasks
Carrying out simple or complex and coordinated actions as components of multiple, integrated
and complex tasks in sequence or simultaneously.
Inclusions: undertaking multiple tasks; completing multiple tasks; undertaking multiple tasks
independently and in a group.
d230 Carrying out daily routine
Carrying out simple or complex and coordinated actions in order to plan, manage and complete
the requirements of day-to-day procedures or duties, such as budgeting time and making plans
for separate activities throughout the day.
Inclusions: managing and completing the daily routine; managing one's own activity level.
d410 Changing basic body position
Getting into and out of a body position and moving from one location to another, such as getting
up out of a chair to lie down on a bed, and getting into and out of positions of kneeling or
squatting.
Inclusion: changing body position from lying down, from squatting or kneeling, from sitting or
standing, bending and shifting the body's center of gravity.
d415 Maintaining a body position
Staying in the same body position as required, such as remaining seated or remaining standing
for work or school.
Inclusions: maintaining a lying, squatting, kneeling, sitting and standing position.
d420 Transferring oneself
Moving from one surface to another, such as sliding along a bench or moving from a bed to a
chair, without changing body position.
Inclusions: transferring oneself while sitting or lying.
d430 Lifting and carrying objects
Raising up an object or taking something from one place to another, such as when lifting a cup
or carrying a child from one room to another.
Inclusions: lifting, carrying in the hands or arms, or on shoulders, hip, back or head; putting
down.
d440 Fine hand use
Performing the coordinated actions of handling objects, picking up, manipulating and releasing
them using one's hand, fingers and thumb, such as required to lift coins off a table or turn a dial
or knob.
Inclusions: picking up, grasping, manipulating and releasing.
d445 Hand and arm use
Performing the coordinated actions required to move objects or to manipulate them by using
hands and arms, such as when turning door handles or throwing or catching an object.
Inclusions: pulling or pushing objects; reaching; turning or twisting the hands or arms; throwing;
catching.
d450 Walking
25
 Moving along a surface on foot, step by step, so that one foot is always on the ground, such as
when strolling, sauntering, walking forwards, backwards, or sideways.
Inclusions: walking short or long distances; walking on different surfaces; walking around
stacles
d455 Moving around
Moving the whole body from one place to another by means other than walking, such as
climbing over a rock or running down a street, skipping, scampering, jumping, somersaulting or
running around obstacles.
Inclusions: crawling, climbing, running, jogging, jumping, and swimming.
d465 Moving around using equipment
Moving the whole body from place to place, on any surface or space, by using specific devices
designed to facilitate moving or create other ways of moving around, such as with skates, skis,
or scuba equipment, or moving down the street in a wheelchair or a walker.
d470 Using transportation
Using transportation to move around as a passenger, such as being driven in a car or on a bus,
rickshaw, jitney, animal-powered vehicle, or private or public taxi, bus, train, tram, subway, boat
or aircraft.
Inclusions: using human-powered transportation; using private motorized or public
transportation.
d475 Driving
Being in control of and moving a vehicle or the animal that draws it, travelling under one’s own
direction or having at one’s disposal any form of transportation, such as a car, bicycle, boat or
animal-powered vehicle.
Inclusions: driving human-powered transportation, motorized vehicles, animal-powered
vehicles.
d510 Washing oneself
Washing and drying one’s whole body, or body parts, using water and appropriate cleaning and
drying materials or methods, such as bathing, showering, washing hands and feet, face and
hair, and drying with a towel.
Inclusions: washing body parts, the whole body; and drying oneself.
d520 Caring for body parts
Looking after those parts of the body, such as skin, face, teeth, scalp, nails and genitals, that
require more than washing and drying.
Inclusions: caring for skin, teeth, hair, finger and toe nails.
d530 Toileting
Planning and carrying out the elimination of human waste (menstruation, urination and
defecation), and cleaning oneself afterwards.
Inclusions: regulating urination, defecation and menstrual care.
d540 Dressing
Carrying out the coordinated actions and tasks of putting on and taking off clothes and footwear
in sequence and in keeping with climatic and social conditions, such as by putting on, adjusting
and removing shirts, skirts, blouses, pants, undergarments, saris, kimono, tights, hats, gloves,
coats, shoes, boots, sandals and slippers.
Inclusions: putting on or taking off clothes and footwear and choosing appropriate clothing.
d550 Eating
Carrying out the coordinated tasks and actions of eating food that has been served, bringing it
to the mouth and consuming it in culturally acceptable ways, cutting or breaking food into
pieces, opening bottles and cans, using eating implements, having meals, feasting or dining.
d570 Looking after one’s health
Ensuring physical comfort, health and physical and mental well-being, such as by maintaining a
balanced diet, and an appropriate level of physical activity, keeping warm or cool, avoiding
harms to health, following safe sex practices, including using condoms, getting immunizations
and regular physical examinations.
Inclusions: ensuring one's physical comfort; managing diet and fitness; maintaining one's
health.
d620 Acquisition of goods and services
Selecting, procuring and transporting all goods and services required for daily living, such as
selecting, procuring, transporting and storing food, drink, clothing, cleaning materials, fuel,
household items, utensils, cooking ware, domestic appliance and tools; procuring utilities and
26
 other household services.
Inclusions: shopping and gathering daily necessities.
d630 Preparing meals
Planning, organizing, cooking and serving simple and complex meals for oneself and others,
such as by making a menu, selecting edible food and drink, getting together ingredients for
preparing meals, cooking with heat and preparing cold foods and drinks, and serving the food.
Inclusions: preparing simple and complex meals.
d640 Doing housework
Managing a household by cleaning the house, washing clothes, using household appliances,
storing food and disposing of garbage, such as by sweeping, mopping, washing counters, walls
and other surfaces; collecting and disposing of household garbage; tidying rooms, closets and
drawers; collecting, washing, drying, folding and ironing clothes; cleaning footwear; using
brooms, brushes and vacuum cleaners; using washing machines, driers and irons.
Inclusions: washing and drying clothes and garments; cleaning cooking area and utensils;
cleaning living area; using household appliances, storing daily necessities and disposing of
garbage.
d650 Caring for household objects
Maintaining and repairing household and other personal objects, including house and contents,
clothes, vehicles and assistive devices, and caring for plants and animals, such as painting or
wallpapering rooms, fixing furniture, repairing plumbing, ensuring the proper working order of
vehicles, watering plants, grooming and feeding pets and domestic animals.
Inclusions: making and repairing clothes; maintaining dwelling, furnishings and domestic
appliances; maintaining vehicles; maintaining assistive devices; taking care of plants (indoor
and outdoor) and animals.
d660 Assisting others
Assisting household members and others with their learning, communicating, self-care,
movement, within the house or outside; being concerned about the well-being of household
members and others.
Inclusions: assisting others with self-care, movement, communication, interpersonal relations,
nutrition and health maintenance.
d710 Basic interpersonal interactions
Interacting with people in a contextually and socially appropriate manner, such as by showing
consideration and esteem when appropriate, or responding to the feelings of others.
Inclusions: showing respect, warmth, appreciation, and tolerance in relationships; responding to
criticism and social cues in relationships; and using appropriate physical contact in
relationships.
d720 Complex interpersonal interactions
Maintaining and managing interactions with other people, in a contextually and socially
appropriate manner, such as by regulating motions and impulses, controlling verbal and
physical aggression, acting independently in social interactions, and acting in accordance with
social rules and conventions.
Inclusions: forming and terminating relationships; regulating behaviors within interactions;
interacting according to social rules; and maintaining social space.
d730 Relating with strangers
Engaging in temporary contacts and links with strangers for specific purposes, such as when
asking for directions or making a purchase.
d740 Formal relationships
Creating and maintaining specific relationships in formal settings, such as with employers,
professionals or service providers.
Inclusions: relating with persons in authority, with subordinates and with equals
d750 Informal social relationships
Entering into relationships with others, such as casual relationships with people living in the
same community or residence, or with co-workers, students, playmates or people with similar
backgrounds or professions.
Inclusions: informal relationships with friends, neighbors, acquaintances, co-inhabitants and
peers.
d760 Family relationships
Creating and maintaining kinship relationships, such as with members of the nuclear family,
extended family, foster and adopted family and step-relationships, more distant relationships
27
 such as second cousins, or legal guardians.
Inclusions: parent-child and child-parent relationships, sibling and extended family
relationships.
d770 Intimate relationships
Creating and maintaining close or romantic relationships between individuals, such as husband
and wife, lovers or sexual partners.
Inclusions: romantic, spousal and sexual relationships.
d820 School education
Gaining admission to school, Education, engaging in all school-related responsibilities and
privileges, and learning the course material, subjects and other curriculum requirements in a
primary or secondary education program, including attending school regularly, working
cooperatively with other students, taking direction from teachers, organizing, studying and
completing assigned tasks and projects, and
advancing to other stages of education.
d830 Higher education
Engaging in the activities of advanced educational programs in universities, colleges and
professional schools and learning all aspects of the curriculum required for degrees, diplomas,
certificates and other accreditations, such as completing a university bachelor's or master's
course of study, medical school or other professional school.
d850 Remunerative employment
Engaging in all aspects of work, as an occupation, trade, profession or other form of
employment, for payment, as an employee, full or part time, or self-employed, such as seeking
employment and getting a job, doing the required tasks of the job, attending work on time as
required, supervising other workers or being supervised, and performing required tasks alone
or in groups.
Inclusions: self-employment, part-time and full-time employment.
d859 Work and employment, other specified/unspecified
d920 Recreation and leisure
Engaging in any form of play, recreational or leisure activity, such as informal or organized play
and sports, programs of physical fitness, relaxation, amusement or diversion, going to art
galleries, museums, cinemas or theatres; engaging in crafts or hobbies, reading for enjoyment,
playing musical instruments; sightseeing, tourism and travelling for pleasure.
Inclusions: play, sports, arts and culture, crafts, hobbies and socializing.

ENVIRONMENTAL FACTORS
= the physical, social and attitudinal environment in which people live and conduct their lives.
e110 Products or substances for personal consumption
Any natural or human-made object or substance gathered, processed or manufactured for
ingestion.
Inclusions: food and drugs.
e125 Products and technology for communication
Equipment, products and technologies used by people in activities of sending and receiving
information, including those adapted or specially designed, located in, on or near the person
using them.
Inclusions: general and assistive products and technology for communication.
e310 Immediate family
Individuals related by birth, marriage or other relationship recognized by the culture as
immediate family, such as spouses, partners, parents, siblings, children, foster parents,
adoptive parents and grandparents.
e320 Friends
Individuals who are close and ongoing participants in relationships characterized by trust and
mutual support.
e325 Acquaintances, peers, colleges, neighbors etc.
Individuals who are familiar to each other as acquaintances, peers, colleagues, neighbors, and
community members, in situations of work, school, recreation, or other aspects of life, and who
share demographic features such as age, gender, religious creed or ethnicity or pursue
common interests.
e330 People in positions of authority

28
 Individuals who have decision-making responsibilities for others and who have socially defined
influence or power based on their social, economic, cultural or religious roles in society, such
as teachers, employers, supervisors, religious leaders, substitute decision-makers, guardians
or trustees.
e355 Health professionals
All service providers working within the context of the health system, such as doctors, nurses,
physiotherapists, occupational therapists, speech therapists, audiologists, orthotist-prosthetists,
medical social workers.
e450 Individual attitudes of health professionals
General or specific opinions and beliefs of health professionals about the person or about other
matters (e.g. social, political and economic issues), that influence individual behavior and
actions.
e570 Social security services, systems and policies
Services, systems and policies aimed at providing income support to people who, because of
age, poverty, unemployment, health condition or disability, require public assistance that is
funded either by general tax revenues or contributory schemes.

4.5 Reliability of the clinician-rated activity measure (Paper IV)

In the development process of the clinician-rated activity measure (Paper IV), 4 of 7 items
were excluded due to low inter-item correlation. The remaining 3 items that constitute the
Shoulder Activity Scale are: lifting an object to a shelf, putting on a jacket and moving the
arm sideways (Appendix 2). These items were linked to the ICF categories lifting and
carrying objects (d430), dressing (d540) and hand and arm use (d445), respectively. In
addition, the purpose of the scale was linked to the category control of voluntary movement
(b760).

In the recruitment of patients to the test-retest study, 94 patients were eligible, of these, 29
patients did not accept participation and 2 were excluded because of generalised pain. A
total of 63 patients with a mean age of 53.3 years (SD = 12.9), 30 women and 33 men, were
included in the study. Three patients dropped out between the baseline test and the retest.
The mean duration of symptoms was 46.6 months (SD = 72.3). According to the employment
status, 38 patients were working, 8 were sick-listed and 17 were either retired, receiving
disability benefits or unemployed. The mean SPADI score at baseline was 36.2 (SD = 16.6).

The item-to-item correlations for the Shoulder Activity Scale ranged between 0.30 and 0.49,
and the item-to-total between 0.70 and 0.82. The Cronbach’s alpha of consistency for the
summed-score was calculated as α = 0.86. There were no significant correlations or non-
linear associations between the participants’ ages or duration of symptoms and the Shoulder
Activity Scale score.

29
The summed-score of the Shoulder Activity Scale has a possible range of 3 (no difficulties) to
15 (cannot perform). The mean summed-score at the test and retest was 6.81 (SD = 2.38).
The inter-rater reliability was calculated to be 0.80 (95% CI = 0.51 - 0.90) and the test-retest
reliability was 0.74 (95% CI = 0.58 – 0.84). The minimal detectable change was calculated to
be 3.32.

5. DISCUSSION

5.1 Methodological considerations

5.1.1 Subjects and material

The intention of the literature review (Paper I) was to identify the most frequently addressed
aspects of functioning in measures used in assessment of shoulder pain. To reduce the large
number of articles that were retrieved from the literature search (n = 13511), we decided that
studies with less than 31 patients should be excluded. Low sample size may in some cases
imply poor methodological quality of the study. However, studies that require advanced
technical equipment, for example movement analyses often have low sample sizes. Due to
this, concepts referring to movement-patterns may have been underestimated in the
material. In the ICF, these are covered by the movement body functions.

The patients in the cross-sectional study (Paper II) were interviewed in an outpatient clinic at
the Department of Physical medicine and Rehabilitation, Oslo University Hospital – Ullevaal.
The outpatient clinic receives approximately 750 patients with shoulder pain annually. The
distribution according to diagnoses, gender and age in the present study was quite similar to
the annual patient cohort at the clinic. Moreover, the functional level (the Shoulder Pain and
Disability Index total score) was quite equal to those enrolled in a previous randomised
controlled trial on patients with rotator cuff disease at the department [139]. Compared with
other samples, a Dutch prospective follow-up study on patients with shoulder pain in general
practice reported similar distribution of gender, age and diagnoses [44]. The functional level
of the patients in our study was similar to that reported in a hospital-treated sample of
patients with shoulder-related diagnoses in Canada and a sample of patients with shoulder
30
pain in general practice in the UK [91, 140]. These comparisons indicate that the present
study sample were representative for the patient cohort at the included hospital and also did
not seem to differ to any great extent from other shoulder pain patient cohorts regarding
gender, distribution of diagnoses and functional level.

In the test-retest study (Paper IV), 63 patients with a primary diagnosis of subacromial
impingement syndrome at the Department of Physiotherapy, Martina Hansen Hospital -
Baerum, were recruited. No statistics on the annual cohort at the hospital were available.
However, the mean age of the participants was 53.3 years (SD = 12.9) which was somewhat
lower than in another study on patients with small and medium-sized tears of the rotator cuff
at the hospital [141]. The gender distribution was approximately equal, whereas the mean
age and the functional level were somewhat higher than in the cross-sectional study with
patient interviews (Paper II).

The classification systems for shoulder pain have been criticised for being focused on
pathological findings, having overlapping diagnostic categories and for having conceptual
inconsistencies [45-50]. Due to this, careful conclusions should be drawn regarding the
distribution of diagnoses in the cross-sectional study (Paper II) and the diagnostic decisions
in the test-retest study (Paper IV). However, in the outpatient clinic at Ullevaal, standardised
diagnostic criteria were applied in the diagnostic process [142, 143]. This probably
contributed to improved reliability in the diagnostic decision process.

Two-thirds of the patients in the cross-sectional study (Paper II) reported additional neck pain
and almost one-third reported low back pain. Additional pain or symptoms in other body
regions, in particular the chest region, have been found to predict higher disability levels [65-
67]. However, this neck and back pain may be symptoms of the abnormal movement
patterns in the upper extremities rather than indication of a widespread pain condition. No
analyses were conducted to investigate whether the disability differed between those who
reported additional pain and those who did not.

The identification of body structure categories in the cross-sectional study was made
according to the symptom description of the diagnostic criteria, thus only three structural
categories related to the shoulder were identified. This is however a matter of case definition.
The challenges with using topography as the main criterion for classification (such as in
back-, neck- and shoulder pain) were outlined in a previous paper [144].

Shoulder pain is a common complaint among patients with stroke, rheumatoid arthritis or
tetraplegia/paraplegia [145-147]. None of these conditions were represented in the patient

31
populations of the present studies (Papers I, II and IV). Thus it is not possible to conclude
whether the results of the current study represent a comprehensive picture of shoulder pain
for these patients.

5.1.2 Procedures and measures

In the literature review (Paper I), the Medical Outcomes Study 36-item Short-Form Health
Survey (SF-36) and a few other measures had previously been linked to the ICF [8, 9]. In the
linking of the SF-36, no ICF categories belonging to interpersonal interactions and
relationship of activities and participation were identified. In our opinion, the SF-36 item that
reads: “during the past 4 weeks, how much of the time has your physical health or emotional
problems interfered with your social activities (like visiting friends, relatives etc.)” and another
similar item should have been linked to interpersonal interactions/relationships categories in
the activities and participation [23]. Due to the high number of citations for the SF-36, this
would have contributed to substantially higher frequency estimates for these ICF categories.
Based on our experiences, extensive knowledge not only of the ICF but also in rehabilitation
is required to achieve reliable linking results. Unfortunately, few clinical experts are familiar
with the ICF linking rules.

The linking rules were updated in 2005, and in our opinion some of the revisions were
unfortunate [9]. For example, the rule that stated that all different constructs in items should
be linked to different categories, was removed [8]. This may contribute to a more semantic
linking procedure in which the underlying constructs are less emphasized.

In the cross-sectional study with patient interviews (Paper II), an Extended ICF Checklist was
applied for the interviews (Appendix 1). This condition-adapted checklist was developed from
the generic ICF Checklist Version 2.1a, according to previous recommendations [113]. In this
process, the generic ICF Checklist was supplemented with ICF categories from the linked
content of condition-specific measures. However, as demonstrated in the literature review
and the comparison with the patient experiences (Papers I and III), the content of the
condition-specific measures of shoulder pain is often limited and does not always match the
patient experiences. Because of this, adaption of the generic checklist should also have
considered other categories, for example those that were identified in the patient interviews
for the musculoskeletal ICF Core Sets. Nevertheless, the low number of ICF categories that
were identified within environmental factors was not caused by this limitation; the generic ICF
Checklist version 2.1a contains a total of 37 environmental categories, and all of these were
implemented in the Extended ICF Checklist. Another methodological decision that should be
considered is the application of the ICF qualifier scale in the patient interviews. Consistent

32
with previous studies, functional problems or environmental factors registered as “mild” (1) to
“complete” (4) in the ICF ordinal scale, was classified as a problem, barrier or facilitator. The
reliability of the ICF ordinal scale in patient interviews has been questioned: In a study on
patients with rheumatoid arthritis, the reliability of the scale increased when the number of
response categories was reduced from five to three [148]. As a consequence, collapsing the
response categories “mild” (1) – “moderate” (2), and “severe” (3) – “complete” (4), was
suggested for body functions and structures and activities and participation [148]. For
environmental factors collapsing the response categories into one single category was
suggested for each of the negative (barrier) and positive (facilitator) factors [148]. A
modification of the scale according to these recommendations could have altered the
responses of the patients during the interviews.

The preliminary list of ICF categories for shoulder pain (Thesis) was identified from the
datasets of the cross-sectional study with patient interviews (Paper II) and the literature
review (Paper I). In the development processes of the ICF Core Sets, an additional
qualitative study with patient interviews (usually focus groups), a global survey with the
participation of clinical experts and a formalised consensus conference were conducted [10].
Furthermore, it needs to be taken into consideration that the patients in the present cross-
sectional study were recruited from one clinic. Due to large variations between the ICF Core
Stets, it is not possible to draw definite conclusions regarding the contribution from these
additional elements.

The functional level of the patients in the cross-sectional study (Paper II) and the test-retest
study (Paper IV) was assessed with the Shoulder Pain and Disability Index (SPADI).
Alternatively, a more comprehensive condition-specific measure, such as the Disability of the
Arm, Shoulder and Hand (DASH) scale could have been applied. However, at the time when
the studies were conducted, the SPADI was routinely used at both hospitals were the data
were collected. Furthermore, a cross-culturally adapted Norwegian version of the DASH
scale was not available.

5.1.3 Analyses
In the literature review (Paper I), frequencies for the identified ICF categories were based on
the number of times their corresponding concept appears in the clinical literature. Due to the
calculation method the ICF categories received rather low frequencies. Alternatively, the
frequency could have been calculated from the number of articles that mentioned a concept.
Although the alternative method would have led to higher frequencies for the ICF categories,

33
their ranking would have ended up being similar. Both of these calculation methods have
been used in previous core set development processes.

In the test-retest study (Paper IV), the minimal detectable change was calculated to be 3.32.
Thus a change score of at least 4 is required to exceed the measurement error in individual
patients. However, this change score is not necessarily clinically important. The minimal
important difference (responsiveness) has been defined as the ability of a measure to detect
clinically important changes over time in the construct to be measured [123]. There are two
different methods to calculate the responsiveness: statistically based methods and anchor-
based methods. The anchor-based methods use an external reference, often a patient-
reported global rating of change [119, 149]. Although the concept of global change has
certain strengths, it has been criticised for being vulnerable to patients’ recall biases, and
perceptions of their context and contradicting how people organise their memory [150-152].
The alternative methods to calculate the minimal important difference use formulas that are
based on the variability of the data at the baseline [130, 131, 153]. The supporters of these
statistically derived methods claim to have found a remarkable relationship between the
standard deviation at baseline and the minimal important difference [128, 154]. In the present
study, calculations of the minimal important difference based on these recommended
statistical methods resulted in a lower estimate than the minimal detectable change. Thus,
we suggest that a change score of at least 4 for the Shoulder Activity Scale is also clinically
relevant.

5.2 Result discussion

5.2.1 Patient experiences in relation to the content of measures

The patient experiences of functioning are an invaluable source of information in
rehabilitation. The results from the patient interviews (Paper II) show that problems covered
by neuromuscular and movement-related body functions (b7-chapter) are frequent among
the patients. Categories from this chapter were also covered by the content of many
condition-specific single-item and multi-item measures (Paper I). As expected, sensation of
pain was the most frequent patient-derived category and it was also ranked number one in
the literature review of measures. This is consistent with the findings in a review in primary
care populations with shoulder disorders in which high pain intensity at baseline was
identified as a predictor for a poor outcome [155]. The ICF categories structures of shoulder

34
region, mobility and stability of joint functions and muscle power were frequently derived in
the patient interviews and they were also high ranked based on the measures (Paper III).
Two other high-frequency patient-derived categories muscle endurance and muscle tone,
were not identified in the measures, although there is support to suggest that they are
frequently affected in patients with shoulder pain [73, 81, 156]. These findings suggest that
central aspects of muscle functioning are not covered by the current assessment of shoulder
pain.

The limited attention given towards mental health in the rehabilitation of patients with
shoulder pain has been criticised [157]. Consistent with this criticism, our findings indicate
that high-frequency patient-derived mental health problems are scarcely addressed in
commonly used condition-specific measures (Paper III). In particular, these measures do not
address temperament and personality and energy and drive functions. The clinical
implications of mental health problems have been debated: in a prospective study that
investigated the contribution of psychological distress’ to the score in three condition-specific
outcome measures of shoulder pain, it was concluded that the DASH scores were more
strongly influenced by pain anxiety and depression than the Constant and SST scores [158].
This is consistent with the findings in another study in which higher DASH scores were
significantly associated with depressive symptoms [159]. It has been suggested that mental
health seems to be influenced by the disability and not by the persistence of pain itself in
patients with chronic shoulder pain [56]. These findings indicate that the connection between
mental health, disability and pain is complex. In our opinion, mental functions should be more
comprehensively addressed in condition-specific measures. The importance of mental health
functions in treatment settings remains to be further investigated. It has been suggested that
mental health problems are predictive of a poor outcome in treatment interventions, but two
prospective studies have drawn opposite conclusions [57, 58].

Parallel with the lack of mental health concepts included in the measures, frequent patient-
derived categories of interpersonal interactions/relationships and environmental social
support categories were scarcely represented (Papers I-III). This may reflect previously
established beliefs among health professionals that the environment, in particular the social
and cultural environment has a negligible impact on a person’s functioning [160-162]. The
minimal use of social function and participation measures in the rehabilitation of
musculoskeletal conditions was criticised in a recent paper [163]. The research on the social
environmental factors within the field of shoulder pain has mostly been devoted to the
negative consequences of the lack of social support at the workplace [61, 63, 106, 109, 110,
164, 165]. The results from our patient interviews, however, indicate that the presence of
35
environmental social support from family members, friends, peers, colleagues and health
professionals is more often a facilitator of functioning. More research should be devoted to
investigate the influence of social environmental factors in patients with shoulder pain.

5.2.2 Content variation in condition-specific measures

The content analyses of the condition-specific multi-item measures and the comparison with
the patient experiences (Papers I and III), indicate that they cover a very different number of
ICF categories and match patient-derived categories differently. These content differences
are consistent with the lack of consensus among clinical experts and researchers within the
field [82, 88, 89, 166]. As a consequence of the lack of comprehensiveness in some of the
measures, we suggest that the wide-ranging Disability of the Arm, Shoulder and Hand
(DASH) scale and the American Shoulder and Elbow Surgeons Standardized Form for
Assessment of the Shoulder (ASES) would be appropriate for non-surgical clinical treatment
situations. Our content analyses indicate that the oldest measures are often less wide-
ranging than the more recent measures. For example, the content of the Constant-Murley
Shoulder Score (Constant) and the Rating Sheet for Bankart Repair (Rowe) only cover 4 and
3 ICF chapters, respectively, whereas the more recent DASH 22 and ASES cover 14 ICF-
chapters [68, 71, 96, 133]. In a study that reviewed the content of 36 condition-specific
questionnaires for low back pain within the ICF, similar results were found according to their
coverage of activity limitations and body function impairments [24].

The updated literature search we conducted indicated that the DASH and ASES seem to be
more frequently selected in studies published within the last year. In contrast, the Constant,
the Shoulder Pain and Disability Index (SPADI) and the generic Medical Outcomes Study 36-
item Short-Form Health Survey (SF-36) seemed to be less frequently selected. As long as
the DASH and ASES are applied the SF-36 does not contribute with a large amount of
additional content, according to our analyses within the ICF. Nevertheless, the SF-36 allows
comparisons of outcomes across different populations and in cost-effectiveness studies that
are valuable in research [98]. For clinical settings however, this development may be
advantageous; it is most likely less confusing to apply a single, comprehensive condition-
specific measure, instead of combinations of different types of measures [55, 97, 167].

The comparison between high-frequency patient-derived categories and the content of

commonly used condition-specific measures (Table 1) demonstrates that almost one third of
these categories are not covered by any of these measures. This is an indication that they
may not be solid enough regarding how well the content adequately reflects the construct to
be measured [123]. Although the measurement properties of the condition-specific measures

36
have been reviewed in a number of studies, little attention has been paid to the content of the
measures [91-93, 95, 168]. This is parallel with the often scarce attention that is paid to
establishing content validity in methodological studies; for example, only construct,
convergent and discriminant validity were reported for the ASES in the original validation
study [169]. The ICF and the linking rules can prove to be useful tools in establishing content
validity for measures in future studies [8, 9].

5.2.3 The added value of clinician-rated movement measures

Within the field of shoulder pain, activity limitations are often assessed by measures that are
patient-reported or contain patient-reported sections [53, 170]. The results from a number of
studies suggest that the correlation between patient-reported and clinician-rated measures is
generally low or moderate [171-176].

As part of the development process, the Shoulder Activity Scale (Appendix 2) was linked to
the activities lifting and carrying objects, dressing, and hand and arm use and to the body
function control of voluntary movement. Of these ICF categories, only the latter was not
identified in the content of the measures or in the patient interviews (Papers I and II). As
previously discussed in the method section, this may be explained by one of the exclusion
criteria in the literature review. Another explanation is the lack of a simple and clinical
measure that covers movement functions. Substantial research supports that abnormal
movement patterns are involved in the development or maintenance of shoulder pain and
restoration of movement-patterns is often an aim in treatment interventions [73, 75-81, 177-
179]. As such, the content of the Shoulder Activity Scale cover key aspects of many
treatment interventions.

The minimal availability of clinician-rated activity measures in shoulder pain rehabilitation is

different from other rehabilitation fields and has been criticised [25, 103]. The clinician-rated
measures have the advantage of directly measuring the unit of interest. Furthermore, they
reflect the current situation and they are less vulnerable to the patient’s recall, language, and
problems with vision or literacy [180, 181]. Because the testing takes place in a standardised
environment, they may provide information about the patients’ domestic environment. With
the development of the Shoulder Activity Scale, a new simple clinician-rated measure testing
movement activities is available. To our knowledge, only two other similar measures exists,
the Bostrom- and the FIT-HaNSA scales [99, 182]. However, the Bostrom scale assesses
four shoulder movements: hand-raising, hand behind the back, hand to neck and hand to
opposite shoulder in front of the body [182]. In the ICF language all these movements are
covered by neuromuscular and movement-related body functions (b7-chapter). The other

37
scale, the FIT-HaNSA, measures the number of times participants are able to perform
movement-tasks that require grip/manipulation of the hand, elbow and shoulder [99].
Although the content of the FIT-HaNSA covers similar activity ICF categories as the Shoulder
Activity Scale, its purpose is different. In the FIT-HaNSA scale, the purpose is to measure the
number of repetitions, regardless of the quality of the movement. In addition to these
clinician-rated scales, at least two assessment methods of scapular kinematics are available
[183-185]. These methods are however different from the Shoulder Activity Scale because
they are aimed at identifying abnormal movement in a single body segment, the scapula.

Among physiotherapists, it is often assumed that they have a common understanding of

abnormal movement patterns. The results of the test-retest study support this assumption,
given some premises. It has been suggested that tests that reflect familiar tasks and have
discrete starting and ending points appear to have the best chance to achieve high reliability
ratings [186]. The movement tasks of the Shoulder Activity Scale are most likely consistent
with these recommendations and the reliability calculations were also higher than in other
studies that have investigated clinician-rated activity measures [186]. The basic mechanisms
underlying the abnormal movement patterns have to some extent been investigated in
electromyography analyses of muscles [75-81]. Further studies with movement analyses
may increase the knowledge about abnormal movement-patterns in the upper extremities.
The Shoulder Activity Scale is a simple, clinician-rated measure that fills a gap in the present
assessment methods. Before it is applied in clinic, it needs to be validated.

5.2.4 A comprehensive picture of shoulder pain within the ICF framework

The categories identified in the literature review of the measures and the cross-sectional
study with patient interviews constitutes a preliminary list of 68 ICF categories for shoulder
pain (Table 2). This section focuses on how the condition is perceived in the ICF language.

More than half (n = 38) of the ICF categories in the list cover activity limitations and
participation restrictions, underlining how defining these aspects of functioning are for
shoulder pain. Within the body functions and structures, a large majority of the 21 categories
covered neuromuscular and movement-related- and mental functions (Figure 2). The list
covers only 9 environmental factors. Of these 5 belong to the support and relationships
chapter, covering support from family, friends, peers, colleagues and health professionals.
Altogether, the list confirms that the disability associated with shoulder pain is multi-faceted.

38
Figure 2. Distribution of categories in the preliminary list for shoulder pain (n = 68) in relation
to ICF chapters

The present, preliminary list of ICF categories for shoulder pain has some similarities with the
comprehensive musculoskeletal ICF Core Sets for low back pain, osteoarthritis,
osteoporosis, rheumatoid arthritis, chronic widespread pain and ankylosing spondylitis [12-
17]. The common categories in five of these musculoskeletal ICF Core Sets were identified in
a previous article [18]. The body functions sleep, emotional functions, pain, mobility of joints,
muscle power and muscle endurance are present in all the ICF Core Sets and in the
preliminary list for shoulder pain. There is only one example of a common body function from
the ICF Core Sets that is not present in the list, namely sensations related to muscles and
movement functions. Concerning activities and participation, all the common categories from
the ICF Core Sets are also present in this list for shoulder pain, except from the participation
function community life.

The largest differences between the present list of ICF categories and the musculoskeletal
ICF Core Sets are among the environmental factors; only 9 categories are identified in the
present list for shoulder pain compared with 25 for low back pain, 17 for osteoarthritis, 26 for
osteoporosis, 21 for rheumatoid arthritis, 34 for chronic widespread pain and 14 for

39
ankylosing spondylitis [12-17]. The environmental categories, social support from immediate
family and support or attitudes of health professionals are present both in the shoulder pain
list and in all five musculoskeletal core sets. Three other environmental categories from the
musculoskeletal core sets are not included in the list for shoulder pain. These are: individual
attitudes of immediate family members, societal attitudes and health services, systems and
policies. Careful conclusions should, however, be drawn due to the less comprehensive
development process of the preliminary list of ICF categories for shoulder pain. The ICF
categories that were common among all five ICF Core Sets, whereas not identified in the
present list, represent future candidate categories for shoulder pain. In addition, this may
also be the case for the body function control of voluntary movement that was linked from the
Shoulder Activity Scale (Paper IV).

The generic ICF Core Set was developed and has been recommended for conditions and
settings in which an ICF Core Set does not exist [19, 20]. All 7 of the ICF categories in the
Generic ICF Core Set are also present in the list for shoulder pain. This finding confirms that
the core categories in other chronic conditions are also relevant in shoulder pain.

5.2.5 Benefit of condition-specific ICF categories

The joint use of the ICD and the ICF has been advocated to capture the full impact of a
health condition on the individual’s functioning [21]. Recently, the Orthopedic Section of the
American Physical Therapy Association (APTA) published a practice guideline for adhesive
capsulitis of the shoulder, and another for shoulder pain and muscle power deficits is under
development [32, 52]. These practice guidelines for the shoulder are part of a series of
guidelines for musculoskeletal conditions from the APTA that are all based on the ICF. In the
guidelines, ICF categories are used to describe clinically relevant problems in functioning
according to body functions and structures, and activities and participation. The purposes of
these guidelines were to categorise patients into mutually exclusive impairment patterns
upon which to base intervention strategies, and serve as measures in changes of function
over the course of an episode of care [32]. Although there was little reference to this in the
guidelines, the identification of these condition-specific ICF categories for adhesive capsulitis
seemed to have been based on decisions by a group of clinical experts without mention of
patient participation. The results that have been presented in the present thesis show that
this method has certain limitations. The ICF Core Set development process represents a
much more comprehensive approach to the identification of condition-specific ICF
categories.

40
In the 11th version of the International Statistical Classification of Diseases and Related
Health Problems. (ICD), that will be finished in 2015, functional properties that are derived
from activities and participation categories in the ICF will supplement the ICD codes, within
some areas [33, 34]. This development implies an increased application of the ICF in the
diagnostic classification of patients. This recent development within the practice guidelines
and the revision of the ICD, imply that that the ICF is increasingly being implemented in
clinical decision-making. To facilitate this, there is a need for condition-specific ICF
categories for shoulder pain that are based on a comprehensive identification process in
which the patient perspective is represented.

6. CONCLUSIONS

6.1 Conclusions

This thesis concerning shoulder pain within the ICF framework, presents the work from a
literature review on commonly used measures, patient interviews with a condition-adapted
checklist, investigation of correspondence between the patient experiences of functioning
and the content of measures, identification of a preliminary list of condition-specific
categories for shoulder pain, and finally, the development process and reliability testing of a
new clinician-rated activity measure. The conclusions that can be drawn are:

x Using the ICF as a reference, a total of 40 ICF categories were identified from the
content of condition-specific and generic measures of shoulder pain. The most
frequently addressed concepts in the measures were pain, movement-related body
functions and structures, sleep, hand and arm use; self-care, household tasks, work
and employment, and leisure activities. Concepts of psycho-social functioning and
environmental factors were less frequently addressed.
x Commonly used condition-specific measures, that contain patient-reported sections,
have large variation in content. The Disability of the Arm, Shoulder and Hand Scale
and the American Shoulder and Elbow Surgeons Standardized Form for Assessment
of the Shoulder were linked to more than twice as many ICF categories as the
Constant-Murley Shoulder Score, the Simple Shoulder Test and the Shoulder Pain

41
 and Disability Index. These large differences signify the importance of clarifying the
content to select the most appropriate measure both in research and in clinical work.
For clinical situations, we propose the use of a wide-ranging condition-specific
measure.
x From the patient interviews with the condition-adapted checklist, a total of 61 ICF
categories were identified, indicating that the patient experiences of shoulder pain are
complex and multi-faceted. The most frequent problems in functioning were related to
the body functions sensation of pain, movement-related functions and mental
functions, and the activity and participation functions mobility, self-care, domestic life,
interpersonal interactions and relationships, work and leisure activities. Within
environmental factors, social support from immediate family and friends were
identified as facilitators of functioning in approximately one of five patients.
x The correspondence between the patient experiences of functioning and the content
of the generic and condition-specific measures was high within activities and
participation, however, more discrepancies were found for body functions and
structures and particularly for environmental factors. Patient-derived categories of the
body functions temperament and personality, emotional functions, muscle endurance
and muscle tone were not identified in the measures; this was also the case for the
environmental factors social support from family, friends, colleagues, employers, and
health professionals and social security and health services.
x Six of 20 high frequency patient-derived ICF categories were not covered by the
content of any of the most commonly used condition-specific measures. This is an
indication that these measures, that contain patient-reported sections, may not be
solid enough regarding how well the content adequately reflects the construct to be
measured.
x A preliminary list of 68 condition-specific, ICF categories for shoulder pain was
identified. Of these categories, 28 were uniquely identified in the patient interviews,
whereas only 7 low-ranked categories from the content of generic and condition-
specific measures were uniquely identified. More than half of the categories in the
preliminary list cover activities and participation. Condition-specific ICF categories
seem to be increasingly applied in clinical decision-making.
x The preliminary list of ICF categories for shoulder pain has similarities with five
musculoskeletal ICF Core Sets, although some differences should be noted: a lower
number of environmental factors are included in the list for shoulder pain, and the
body functions muscle endurance and sensations related to muscles and movement
functions are not present. In addition, activities reflecting individual attitudes of

42
 immediate family members, societal attitudes and health services, and systems and
policies were not identified in the preliminary list of ICF categories for shoulder pain.
x The Shoulder Activity Scale is a simple and reliable clinician-rated activity measure
for patients with shoulder impingement syndrome. The measure focuses on abnormal
movement-patterns in the upper extremities, which is a key concept in treatment
interventions of shoulder pain. Clinician-rated activity measures seem to provide
additional information to the patient-reported measures.

6.2 Implications for clinical practice and research

The present research on shoulder pain within the ICF framework has several implications for
clinical practice. The condition-specific ICF categories that were identified can be applied in
different stages of the clinical practice, such as assessment, goal assignment, and evaluation
of treatment interventions. In most cases, the ICF categories and their explanations should
be easily understood by clinicians and patients.

The lack of comprehensiveness in relation to the patient experiences of functioning in the

content of condition-specific measures should facilitate further debate among health
professionals within the field. Future reviews of the measurement properties of these
measures should pay increased attention to this topic.

The identification of condition-specific categories has been advocated as the starting point to
apply the generic ICF in rehabilitation. The present, preliminary list of ICF categories for
shoulder pain constitutes the most comprehensive overview of shoulder pain within the ICF
framework that is currently available. The list should be applied in development of practice
guidelines for shoulder pain. To improve its feasibility, the list should be further developed
into an ICF Core Set. To our knowledge, there is currently no plan for such attempt.

43
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Roe et al. BMC Musculoskeletal Disorders 2013, 14:73
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RESEARCH ARTICLE Open Access

A systematic review of measures of shoulder pain

and functioning using the International
classification of functioning, disability and health
(ICF)
Yngve Roe1,3*, Helene Lundegaard Soberg1,2, Erik Bautz-Holter2,3 and Sigrid Ostensjo1

Abstract
Background: Shoulder pain is a common condition with prevalence estimates of 7–26% and the associated
disability is multi-faceted. For functional assessments in clinic and research, a number of condition-specific and
generic measures are available. With the approval of the ICF, a system is now available for the analysis of health
status measures. The aims of this systematic literature review were to identify the most frequently addressed
aspects of functioning in assessments of shoulder pain and provide an overview of the content of frequently used
measures.
Methods: Meaningful concepts of the identified measures were extracted and linked to the most precise ICF
categories. Second-level categories with a relative frequency above 1% and the content of measures with at least 5
citations were reported.
Results: A set of 40 second-level ICF categories were identified in 370 single-item measures and 105 multi-item
measures, of these, 28 belonged to activities and participation, 11 to body functions and structures and 1 to
environmental factors. The most frequently addressed concepts were: pain; movement-related body functions and
structures; sleep, hand and arm use, self-care, household tasks, work and employment, and leisure. Concepts of
psycho-social functions and environmental factors were less frequently included. The content overview of
commonly used condition-specific and generic measures displayed large variations in the number of included
concepts. The most wide-ranging measures, the DASH and ASES were linked to 23 and 16 second-level ICF
categories, respectively, whereas the Constant were linked to 7 categories and the SST and the SPADI to 6
categories each.
Conclusions: This systematic review displayed that measures used for shoulder pain included more than twice as
many concepts of activities and participation than concepts of body functions and structures. Environmental factors
were scarcely addressed. The huge differences in the content of the condition-specific multi-item measures
demonstrates the importance of clarifying the content to select the most appropriate measure both in research
and in clinical work. For clinical situations, we propose use of a wide-ranging condition-specific measure that
conceptualizes assessments of shoulder pain from a bio-psycho-social perspective. Further research is needed to
assess how patient-reported problems in functioning are captured in the commonly used measures.
Keywords: ICF, Outcome assessment (health care), Shoulder pain, Shoulder, Health, Cross-sectional studies,
*Disability evaluation, World health organization, Recovery of function, *Rehabilitation

* Correspondence: yngve.roe@hioa.no
1
Faculty of Health Sciences, Oslo and Akershus University College of Applied
Sciences, Postboks 4 Street Olavs plass, Oslo 0130, Norway
3
Faculty of Medicine, University of Oslo, Oslo, Norway
Full list of author information is available at the end of the article

© 2013 Roe et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
Roe et al. BMC Musculoskeletal Disorders 2013, 14:73
http://www.biomedcentral.com/1471-2474/14/73
Background
Shoulder pain is common in the general population;
prevalence estimates range from 7 to 26 per cent [1].
The large range in the prevalence rates has been
explained by the use of different definitions of the con-
dition in the literature [1]. Pain in the neck or shoulder
emerged as the most frequent work-related health com-
plaint in a Norwegian cohort study, and diagnosed
shoulder pain accounted for almost 18 per cent of all
sick leave benefit claims in a Swedish survey [2,3].
Shoulder pain is characterised by restricted and painful
movement of the arm, which results in difficulties in
performing movement-related activities [4-6]. In recent
decades, research has shown that psychological and so-
cial functioning may also be affected by shoulder pain;
additionally, environmental factors may contribute to
the development or persistence of the condition [7-10].
Functional assessments are an important aspect of cli-
nical decision making and research pertaining to patients
with shoulder pain. A number of condition-specific mea-
sures are available for making these assessments, including
standardised clinical examination methods, patient-
reported questionnaires and composite scores [5,6,11-14].
Whether the condition-specific symptoms should be
limited to movement-related functions of the shoulder
region or be expanded to include additional aspects of
functioning, such as work, leisure activities and sleep qua-
lity has been debated [12,15]. To make the assessments
more comprehensive and to facilitate comparisons with
other health conditions, some have advocated the inclusion
of generic measures in the assessments [7,13,16]. Generic
measures may focus on a specific function or broadly in-
clude the concept of general health [12]. So far, there are
no commonly accepted guidelines for functional assess-
ment in the area of shoulder pain. Given the increasing
standards of health measurements, considerable research
effort has been devoted to investigating the psychometric
properties of the condition-specific measures [17-24].
Although the content of such measures also needs to be
considered, it often receives less attention [25].
With the approval of the International Classification of
Functioning, Disability and Health (ICF) in 2001, a con-
ceptual framework and classification is now available for
content analysis of functional measures from a bio-
psycho-social perspective [26]. The ICF is based on an
integrative model that classifies functioning within the
components of body functions (b), body structures (s),
activities & participation (d) and environmental (e) and
personal factors (not classified). The ICF classification
provides categories of functioning and environmental
factors that are arranged in a hierarchical fashion using an
alphanumeric coding system. The initial letter refers to
the component. This letter is followed by a numeric code
that starts with the chapter number (e.g., Mobility, d4),
Page 2 of 12
which is followed by the second level (e.g., d445 Hand and
arm use) and then the third level (e.g., d4452 Reaching). A
fourth level of classification is also available when appro-
priate. The categories at a lower level are included in the
higher level categories and chapters. Procedures have been
established to classify the content of functional measures
using ICF categories, regardless of their purpose, their
extent and administration method [27,28].
The ICF classification is comprehensive. Shorter lists of
categories, known as ICF core sets, have been developed
to describe the typical spectrum of problems in the
functioning of patients with a specific health condition
[29]. The core set development process was based on lit-
erature reviews, expert surveys and single quantitative and
qualitative clinical studies. A review investigating com-
monalities across ICF core sets for musculoskeletal
conditions found a large number of common categories
for the conditions low back pain, osteoarthritis, osteopo-
rosis, and rheumatoid arthritis; however, there were also
unique categories associated with each particular condi-
tion [30]. As part of this core set development process, a
literature review was conducted to analyse the content of
measures for each of the musculoskeletal disorders [31].
Such a review based on a bio-psycho-social perspective on
functioning has not been conducted for shoulder pain.
The aims of this systematic literature review were to iden-
tify the most frequently addressed aspects of functioning
in assessments of shoulder pain and provide an overview
of the content of frequently used measures.
Methods
Design
A systematic literature review and content analysis of
measures used in shoulder pain. The steps of the
screening and extraction of measures are displayed in
Figure 1.
Literature search
The inclusion criteria were articles written in English,
published in peer-reviewed journals and based on clini-
cal studies on patients having shoulder pain. A highly
sensitive 15-step search strategy for Medline was de-
veloped (Additional file 1) [32]. The Medline strategy
was also adapted to Embase, PeDro, Cinahl and Central.
The search was limited to studies published between
January 2005 and May 2010. In a first step MeSH-terms
related to shoulder pain were exploded and combined
using the Boolean operator “OR”. Terms used for func-
tional assessments were also combined with the Boolean
operator “OR”. In the next step the MeSH-terms and
the functional assessment terms were combined using
the Boolean operator “AND”.
Articles based on studies of fractures, joint replacement,
complete dislocation, malignant condition, rheumatic
Roe et al. BMC Musculoskeletal Disorders 2013, 14:73
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Abstracts identified
n = 13511
Abstracts for screening
n = 9711
Articles for full text screening
n = 1591
Articles for measure extraction
n = 515
Measures for linking
Single-item: n = 370
Multi -item: n = 105
Figure 1 Flow chart of the literature search with the total number of identified measures and their number of citations.
diagnosis and stroke were excluded, as were studies based
exclusively on laboratory parameters or on a non-human
population. The following designs or types of studies were
also excluded: comments, letters, editorials, guidelines,
conference reports, literature reviews, primary prevention
studies, phase I or II studies, ecologic and economic
evaluations, quantitative studies with less than 31 parti-
cipants and studies on children.
Screening and extraction of measures
All retrieved articles from the databases were imported
to the same Endnote library (version X3, Thomson
Reuters 1500 Spring Garden Street, Philadelphia) and
screened for duplicates. In cases of multiple publications,
the journal with the highest impact factor was selected.
All remaining articles were imported into a Microsoft
Access database (Microsoft Office 2003) for the abstract
screening. Articles meeting any exclusion criteria were
excluded. In cases where the decision was to include the
article or the exclusion decision was ambiguous, full
versions of the articles were retrieved. All abstracts were
screened by one reviewer (YR); a random selection of
20% was also screened by a second reviewer (SO) before
a final decision was made. Another predesigned Access
database was used for the full version screening and
extraction of measures. Where there was doubt as to
which version of a measure had been used, a decision
was made using the references given in the methods
section of an article.
Information on nationality using the address of the
first author, study design and types of interventions was
recorded. The extracted measures were categorised as
either single-item or multi-item measures. Single-item
measures contained only one item, such as imaging and
Page 3 of 12
Total
Total number
of citatations
n = 2469
clinical tests and single questions on different domains;
in contrast, multi-item measures included more than
one test and question, such as different questionnaires
and scales.
Analyses
The content of the measures was linked to the ICF
according to established rules [27,28]. Meaningful
concepts were extracted and linked to the most specific
ICF category possible. Items could contain more than
one concept; for example, I cannot lie on my right side
at night because of my shoulder contains the meaningful
concepts lie on my side and because of my shoulder. The
former was linked to the maintaining a lying position
(d4150) and the latter to the pain in upper limb
(b28014). For concepts not sufficiently specified to be
linked, the non-definable option was chosen. If a concept
was not covered by the ICF classification, the option not
covered was chosen [27,28]. All measures were linked by
one reviewer (YR) and a random selection of twenty-five
per cent of the multi-item measures were also linked by
a second reviewer (SO). The single-item measures were
discussed with a clinician and researcher experienced in
rehabilitation of shoulder pain (KE). The ICF links of ten
measures that had already been published in scientific
journals or were available from previous reviews per-
formed by the ICF Research Branch were accepted for
use in the current study [33,34].
Relative frequencies of the linked second-level ICF ca-
tegories for each component were estimated from the
total number of citations. Only ICF categories that arose
with a frequency of at least 1% are presented. A fre-
quency of 10% was chosen as the arbitrary cut off to
classify a category as high frequent. In cases where
Roe et al. BMC Musculoskeletal Disorders 2013, 14:73
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concepts were linked to a third- or fourth-level category,
they were aggregated to the second level. For example, a
concept linked to the third-level category turning or
twisting the hands or arms (d4453) was reported under
the second-level hand and arm use (d445) category.
When an ICF category was assigned repeatedly in the
same measure, it was only counted once. Moreover, the
content of measures cited in at least 5 different articles
were presented at the ICF chapter level and more
detailed in the Additional file 2.
Reliability of the abstract screening and linking
procedures were measured with percentage agreement
and estimation of Cohen’s Kappa coefficient. The 95%
confidence intervals for the Kappa coefficient were con-
structed using the bias-corrected percentile method
[35,36]. A Kappa coefficient of 0–0.4 was considered poor,
0.41 – 0.60 fair to good and 0.61 – 1.00 excellent [37].
The agreement in the counter-screening of abstracts bet-
ween reviewers was 87.3%. The estimated Kappa coeffi-
cient was 0.62 (95% CI, 0.59 - 0.66), which is considered
good or excellent. The agreement in the linking procedure
between reviewers was 80.8%. The estimated Kappa coeffi-
cient was 0.81 (95% CI, 0.77 - 0.85), which was classified
as excellent.
Results
Literature search
A total of 13,511 articles were identified through the li-
terature search; of these articles, 1591 full versions were
screened, and 515 were included. Altogether 475 dif-
ferent measures were extracted with a total of 2469
citations. Among them, 370 were single-item measures
and 105 were multi-item measures. A total of 20,517
meaningful concepts were extracted from the measures,
of which 86.3% were linked to the ICF. The share of
concepts that were not covered or not definable was
13.7%. The procedure is displayed in Figure 1.
Study characteristics
According to nationality, Europe accounted for 44% of
the articles, Canada and USA for 32% and Asia for 15%.
Approximately 9% of the articles were from other
continents. Sixty per cent of the articles contained stu-
dies with an interventional design (e.g., randomised con-
trolled trial or case control trial), while thirty-nine per
cent of articles were based on an observational study
(longitudinal or cross-sectional). Only a single article
based on a qualitative study was present in the sample.
Ninety-one per cent of the articles included participants
with a diagnosed shoulder condition, of whom 52% were
diagnosed with subacromial pain conditions, 17% with
instability or SLAP-lesions, 9% with adhesive capsulitis,
18% with mixed diagnoses and 4% with other diagnoses.
Page 4 of 12
Nine per cent of the articles included individuals with
self-reported shoulder conditions only.
Second-level ICF categories linked to concepts contained
in the measures
A total of 40 second-level ICF categories with a fre-
quency above 1% were identified in the components of
body functions and structures, activities and participa-
tion and environmental factors.
Eleven second-level ICF categories were identified
within the body functions and structures component, as
shown in Table 1. Of these, five categories were located in
the neuromusculoskeletal or movement related functions
(b7) chapter, three in mental functions (b1), two in sensory
functions and pain (b2) and one in structures related to
movements (s7). The five second-level categories with a
relative frequency above 10% were sensation of pain
(b280), mobility of joint functions (b710), structure of
shoulder region (s720), muscle power functions (b730) and
sleep functions (b134).
As displayed in Table 2, 28 second-level ICF categories
were identified within the activities and participation
component. Of these, eight categories had a relative fre-
quency above 10%. Nine categories belonged to the mo-
bility chapter (d4), six to self-care (d5), four to domestic
life (d6), three to interpersonal interactions and rela-
tionships (d7) and major life areas (d8), and one cate-
gory each to the chapters of community, social and civic
life (d9), learning and applying knowledge (d1) and ge-
neral tasks and demands (d2). The eight categories with
a frequency above 10% were, in ranked order: hand and
arm use (d445), remunerative employment (d850), re-
creation and leisure (d920), lifting and carrying objects
(d430), washing oneself (d510), dressing (d540), caring
for body parts (d520) and doing housework (d640).
Table 1 Relative frequency (%) of second level ICF
categories linked to the concepts contained in the
measures for the ICF component body functions and
structures (n= 2469) in ranked order
ICF second level categories (n=11) (%)
b280 Sensation of pain 47,3
b710 Mobility of joint functions 34,7
s720 structure of shoulder region 24.9
b730 Muscle power functions 24,2
b134 Sleep functions 17,5
b715 Stability of joint functions 7,1
b152 Emotional functions 6,3
b780 Sensations related to muscles and movement functions 3,3
b130 Energy and drive functions 3,1
b265 Touch function 2,3
b720 Mobility of bone functions 2,1
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Table 2 Relative frequency (%) of second level ICF included categories from both the body functions and
categories linked to the concepts contained in the structures and activities and participation components
measures for the ICF component activities and of the ICF. Of these, the DASH and ASES were the most
participation (n= 2469) in ranked order wide-ranging, containing meaningful concepts linked to
ICF second level categories (n=28) (%) categories in 11 and 9 chapters, respectively. By contrast,
d445 Hand and arm use 24,5 the Shoulder Pain and Disability Index (SPADI) and the
d850 Remunerative employment 23,2 Walch-Duplay Score only contained categories belo-
d920 Recreation and leisure 18,3 nging to three ICF chapters. The most-frequently cited
d430 Lifting and carrying objects 17,1 generic measure, the MOS 36-item short-form health
d510 Washing oneself 17 survey (SF-36) (46 citations), was linked to seven
d540 Dressing 15,8
chapters: two of which were in the body functions and
structures component, and five of which were in the ac-
d520 Caring for body parts 12,7
tivities and participation component.
d640 Doing housework 10,4
Of the condition-specific measures, the ASES, UCLA
d415 Maintaining a body position 6 and the Rating Sheet of Bankard repair (Rowe) also
d230 Carrying out daily routine 4,5 included concepts that were linked to an environmental
d475 Driving 4,7 factor, all of which belonged to the products and tech-
d530 Toileting 3,6 nology (e1) chapter. Only one of the generic measures,
d650 Caring for household objects 3,6 the Job Content Questionnaire (JCQ), included environ-
d620 Acquisition of goods and services 3,4 mental factors. Its content was linked to two chapters
d470 Using transportation 3,6 other than products and technology (e1); specifically, it
d760 Family relationships 3
was also linked to the natural environment and human-
made changes to environment (e2) and support and
d550 Eating 2,9
relationships (e3) chapters.
d450 Walking 2,8
The most comprehensive measure of mental functions
d410 Changing basic body position 2,6
(b1) was the generic Four-Dimensional Symptom Ques-
d630 Preparing meals 2,6 tionnaire (4DSQ). It includes concepts linked to five
d750 Informal social relationships 2,6 second-level categories: consciousness functions (b110),
d455 Moving around 2,5 energy and drive functions (b130), sleep functions (b134),
d770 Intimate relationships 2,3 emotional functions (b152) and higher-level cognitive
d859 Work and employment, other specified and unspecified 2,2 functions (b164). The SF-36 had concepts linked to two
d170 Writing 2,1 mental function categories: the energy and drive func-
d440 Fine hand use 2,1 tions (b130) and emotional functions (b152). Of the
condition-specific measures, none of the most cited
d570 Looking after one’s health 1,1
contained other mental functions than sleep functions
d820 School education 1
(b134). The UCLA (the third most cited) did not address
any mental functions (b1) concepts. Looking at employ-
In the ICF component of environmental factors, the ment and leisure activities, the content of 11 of the 16
only identified second-level category was products or condition-specific measures was linked to remunerative
substances for personal consumption (e110). This ca- employment (d850), eight to recreation and leisure (d920)
tegory which was located in the products and technology and seven of the measures to both ICF categories. The
(e1) chapter had a relative frequency of 8.8%. UCLA, SPADI, the Shoulder Disability Questionnaire
(SDQ) and the Flexilevel Scale of Shoulder Function
Distribution of ICF codes within the measures (FLEX-SF) contained no concepts related to work and lei-
The 16 condition-specific and 7 generic multi-item sure. Of the seven generic measures, five included work
measures with five or more citations are displayed in functions; only one, the SF-36, asked for information
Table 3. By far the most cited were Constant-Murley about leisure activities.
Shoulder Score (Constant) (124 citations), followed by The 28 condition-specific and 7 generic single-item
the American Shoulder and Elbow Surgeons stan- measures with five or more citations are displayed in
dardized form for assessment of the shoulder (ASES) Table 4. Patient-reported shoulder pain intensity was the
(77 citations), the University of California at Los Angeles most frequently cited (200 citations) followed by active
shoulder rating scale (UCLA) (64 citations) and the range of motion (170 citations), Magnetic Resonance
Disability of the Arm, Shoulder and Hand scale (DASH) Imaging (MRI/MRA) (125 citations), muscle strength
(51 citations). All of the condition-specific measures (98 citations), X-ray (81 citations), passive range of
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motion (61 citations) and ultrasonography (57 citations).
The measures contained concepts that were linked to
categories in three ICF chapters of the body functions
and structures component: sensory functions and pain
(b2), neuromusculoskeletal or movement related func-
tions (b7) and structures related to movements (s7). By
contrast, the generic single-item measures were (with
one exception) linked to categories of activities and par-
ticipation or environmental factors. These categories
belonged to the self-care (d5), major life areas (d8), com-
munity, social and civic life (d9) and products and tech-
nology (e1) chapters. Two measures that requested the
use of medication or smoking habits were the only
concepts of environmental factors among the single-
item measures.
Discussion
Using the ICF as a reference, we first identified and
quantified the concepts included in frequently used
measures of shoulder pain and functioning. The content
of the measures was linked to 11 different ICF categories
within 3 of 8 domains of body functions and structures,
and 28 ICF categories within 8 of 9 domains of activities
and participation. Environmental factors were scarcely
addressed, accounting for only one category. The finding
displays that the measures of shoulder pain cover a large
number of concepts of daily activities and also some par-
ticular concepts of body functions.
As expected, the ICF category sensation of pain was
highest ranked. Different concepts of pain were re-
quested in both condition-specific single and multi-item
measures and also in generic measures. This is consis-
tent with previous recommendations to regard pain as a
global construct measured by pain intensity and by in-
terference with activities [59]. In a systematic literature
review on prognostic factors in primary care populations
of shoulder disorders, strong evidence was found that
high pain intensity at baseline predicts a poor outcome
[60]. The ICF categories mobility of joint, structures of
the shoulder region and muscle power functions were

Table 3 Number of citations and content overview at ICF chapter-level of the most frequently identified multi-item
measures
Cond-spec. Number Mental Sensory functions Neuromuscular Structures Learning and General task Mobility
measures of citations functions (b1) and pain (b2) and movement related to applying and demands (d4)
(n=16) (b7) movement knowledge (d2)
(s7) (d11)
Constant 124 √ √ √ √
ASES 77 √ √ √ √ √
UCLA 64 √ √ √
DASH 51 √ √ √ √ √ √
SST 46 √ √ √
Rowe 31 √ √ √
SPADI 31 √ √
WORC 21 √ √ √ √
SRQ 15 √ √ √
SDQ 14 √ √ √
OSS 11 √ √ √
WOSI 8 √ √ √ √ √
QuickDASH 7 √ √ √ √ √
FLEX-SF 6 √ √
Penn 5 √ √
Walch-Duply 5 √ √
Generic measures
(n=7)
SF-36 46 √ √ √ √
SF-12 9 √ √
JCQ 8 √
Nordic 7 √
EQ-5D 6 √ √
FABQ 5 √
4DSQ 5 √ √ √
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Table 3 Number of citations and content overview at ICF chapter-level of the most frequently identified multi-item
measures (Continued)
Cond-spec. Self-care Domestic interpersonal Major life Community, Products and Natural environment Support and
measures (d5) life (d6) interactions areas (d8) social and civic technology(e1) and hum. ch. (e2) relationships
(n=16) and rel. (d7) life (d9) (e3)
Constant √ √
ASES √ √ √ √
UCLA √ √ √
DASH √ √ √ √ √
SST √ √
Rowe √ √ √ √
SPADI √
WORC √ √ √
SRQ √ √ √ √
SDQ √
OSS √ √ √
WOSI √ √ √ √
QuickDASH √ √ √ √
FLEX-SF √ √ √ √
Penn √
Walch-Duply √
Generic measures
(n=7)
SF-36 √ √ √
SF-12 √
JCQ √ √ √ √
Nordic √
EQ-5D
FABQ √
4DSQ
Constant = the Constant Murley shoulder score [5], ASES = the American Shoulder and Elbow Surgeons standardized form for assessment of the shoulder [6],
UCLA = the University of California at Los Angeles shoulder rating scale [38], DASH = the Disability of the Arm, Shoulder and Hand scale [39], SST = the Simple
Shoulder Test [40], SPADI = the Shoulder Pain and Disability Index [41], Rowe = a Rating sheet for Bankard repair [42], WORC = the Western Ontario Rotator Cuff
Index [43], SRQ = the Shoulder Rating Questionnaire [44], SDQ = the Shoulder Disability Questionnaire [45], OSS = the Oxford Shoulder Score [46], WOSI = the
Western Ontario Shoulder Instability Index [47] , QuickDASH = the shortened disabilities of the arm, shoulder and hand questionnaire [48], FLEX-SF = the Flexilevel
Scale of Shoulder Function [49], Penn = the Penn shoulder score [50] , the Walch-Duplay shoulder score [51] , SF-36 = the MOS 36-item short-form health survey
[52] , SF-12 = a 12-Item Short-Form Health Survey [53], JCQ = the Job Content Questionnaire [54], Nordic = the standardized Nordic questionnaires for the analysis
of musculoskeletal symptoms [55], EQ-5D = a measure of health status from the EuroQol Group [56], FABQ = a Fear-Avoidance Beliefs Questionnaire [57], 4DSQ =
the Four-Dimensional Symptom Questionnaire [58].

ranked second, third and fourth, and in most cases
linked from concepts in condition-specific measures.
However, not all such concepts were common in the
measures; the ICF category muscle endurance was not
frequent above the 1% limit, although isometric muscle
endurance has been proposed as a psycho-physiological
measure for shoulder pain [61].
Sleep functions, classified in the ICF as a mental func-
tion, was the fifth most frequent ICF category. Concepts
of sleep were included in many condition-specific and
generic measures, whereas concepts linked to the less
frequent ICF categories emotional functions and energy
and drive were extracted from only a few measures. A
study that included a community based population of
subjects with chronic shoulder pain, found that the rela-
tion between pain and psychological health was
dependent of level of disability [9]. Moreover, a previous
review points to the influence of psychosocial and be-
havioural factors in chronic neck-and-shoulder pain
[62]. According to the current finding, concepts of psy-
chological health may be underestimated in commonly
used measures of shoulder pain. However, one compre-
hensive measure on psychological functioning was
found, the generic 4DSQ, which captured five different
mental functions according to the ICF.
Several of the predominant concepts in measures of
shoulder pain and functioning, were in the activities and
participation component. Ten ICF categories belonged
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Table 4 Number of citations and content overview at ICF chapter-level of the most frequently identified single-item
measures
Cond-spec. Number Mental Sensory Neuromuscular Structures Self-care Major Community, Products
measures (n=28) of citations functions functions and movement related to (d5) life social and and
(b1) and pain (b2) (b7) movement (s7) areas civic life (d9) technology
(d8) (e1)
Patient-report pain 200 √
intensity
Active range of 170 √
motion
Magnetic 125 √
Resonance Imaging
(MRI/MRA)
Muscle strength 98 √
X-ray 81 √
Passive range of 61 √
motion
Ultrasonography 57 √
Hawkins-Kennedy 47 √ √
test
Neer test 41 √ √
Painful arc 27 √ √
Apprehension test 25 √ √
Resisted isometric 22 √ √ √
abduction
Arthroscopic 18 √
examination of the
shoulder
Active compression 17 √ √ √
test (O’Brian)
Lift-off test 16 √ √ √
Speed test 15 √
Impingement signs 13 √
Electromyelography 12 √
(EMG)
Relocation test 10 √ √
(Jobe relocation)
Yergason test 10 √ √
Palpation sensitivity 9 √
rotator cuff/biceps
Empty can test 9 √ √
Sulcus sign 8 √ √
Jobe test for 8 √ √
supraspinatus
(Fulcrum’s test)
Belly press test 6 √ √ √
Compression- 5 √ √
rotation test
Instability testing 5 √
shoulder
Drop arm test 5 √ √ √
Generic measures
(n=7)
Work absenteism 31 √
Medication 15 √
Roe et al. BMC Musculoskeletal Disorders 2013, 14:73
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Table 4 Number of citations and content overview at ICF chapter-level of the most frequently identified single-item
measures (Continued)
Smoking habits 14
Sport activity 17
Comb hair 7 √
Physical activity 7 √
Sleep quality 5 √
to mobility functions and five each to self-care and
domestic life. Hand and arm use and lifting and carrying
were both among the five highest ranked activities and
participation categories. Concepts linked to these two
ICF categories were extracted from almost all the
condition-specific multi-item measures (see Additional file
2). This demonstrates that task orientated movements of
the upper-extremity is in the core of the assessment of
shoulder pain. The high ranking of the ICF category
remunerative employment, was consistent with the high
numbers reporting work-relatedness of their shoulder dis-
order in a previous epidemiological study [2]. Work-
related concepts were addressed in a majority of the
multi-item condition-specific measures, although the
UCLA, SPADI and SDQ did not address any concepts of
work. In a recent review of concepts in vocational
rehabilitation measures, a number of work-related con-
cepts were extracted [63]. One of the commonly used vo-
cational measures, the JCQ was also identified in the
current review [54]. Its comprehensiveness indicates that
assessments of work need to capture several different
functional domains.
Previous research shows that also social functioning
may be affected by shoulder pain [7-10]. Family-, informal
social- and intimate relationship, all appeared among the
lower ranked ICF categories and these concepts were
included in only one condition-specific measure, the
DASH. Although the SF-36 contains a social subscale,
none of its concepts were linked to the ICF category inter-
personal interactions and relationships [33]. This indicates
that the SF-36 requests social relationships in a more ge-
neral way and not as specific interpersonal interactions.
Products or substances for personal consumption that
appeared with a relative frequency of 8.8%, was the only
environmental factor above the 1% criteria. This finding
reflects that the impact of the environment on func-
tioning is not sufficiently taken into consideration in the
assessments of shoulder pain. According to the ICF, the
environment contains a large number of physical, social
and attitudinal factors which may limit or facilitate
functioning. Although some previous research has been
devoted to identify risk factors in the workplace environ-
ment, the significance of external factors has scarcely
been addressed within the shoulder pain research [64].
Page 9 of 12
√
√
Concepts measured in different musculoskeletal dis-
orders were identified in a previous review, and of particu-
lar interest for the current study was low back pain [31].
Although there were large similarities between the content
of the shoulder pain and low back pain measures, some
differences emerged. The comparisons showed that the
measures of shoulder pain contained a higher number of
concepts within self-care and domestic life, whereas the
low back pain measures contained a higher number of en-
vironmental factor concepts, concerning support and
relationships to persons and the attitudes of health
professionals.
This review identified 44 condition-specific and 15 gen-
eric measures in use to assess functioning in patients with
shoulder pain. When comparing the content of the single-
and multi-item measures we found that the former
requested only pain and movement related functions,
whereas the latter included a wide range of body functions
and structures, and activities. The wide-ranging DASH
and the ASES were linked to 23 and 16 ICF categories re-
spectively, whereas the Constant was linked to 7 categor-
ies and the Simple Shoulder Test (SST) and SPADI to 6
categories each (see Additional file 2). These comparisons,
using the ICF as a framework, disclose both the simila-
rities and differences in content of measures that all aim
to assess aspects of functioning in patient with shoulder
pain.
The variation in the type and number of concepts in the
condition-specific measures might reflect disparate views
on disability among developers of measures. Some of the
measures, such as the SPADI and the Oxford Shoulder
Score (OSS) were developed to capture joint-specific
concepts and to avoid the influence of co-morbidity
[41,65]. On the contrary, the DASH aims at capture
disability, defined as difficulty in doing activities in any
domain of life [39]. Due to the complexity of the disability
of shoulder pain, and the narrow content of many
condition-specific measures, it has been recommended to
supplement the condition-specific measures with the ge-
neric SF-36 [7,13,16]. However, as demonstrated in the
current study, the SF-36 includes few additional concepts
to those requested in the most wide-ranging condition-
specific measures. Clarifying the content is of great im-
portance for selecting the most appropriate measures in
Roe et al. BMC Musculoskeletal Disorders 2013, 14:73
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clinical work and in research, although the choice of a
measure is also dependent on the purpose, patient popu-
lation and the psychometric properties. In our opinion,
use of a wide-ranging condition-specific measure may
enhance the quality of assessments in many clinical
situations. The wide-ranging (Quick-) DASH and the
ASES were found to be among the most extensively
investigated measures according to measurement proper-
ties in a recent review [24].
The current review had some limitations that should be
noted. Meaningful concepts in the measures referring to
personal factors in the ICF, such as fear avoidance and
coping strategies were not reported. The updated linking
rules enable the identification of personal factors, but they
are still not classified in the ICF [28]. For 10 measures
identified in the study, the content was linked in previous
studies (32, 32). The commonly used SF-36 was analysed
using the first version of the ICF linking rules [27]. Use of
the updated linking rules may have given a somewhat dif-
ferent result [28]. For interpretation of the results, it is of
importance that a particular ICF category was reported
only once for each measure. As such, the content over-
view of the measures provides information on the breadth
of each measure rather than their depth.
Conclusions
Using the ICF as a reference, a total of 40 second-level
categories was used to classify the content of condition-
specific and generic measures of shoulder pain. The most
frequently addressed concepts were pain, movement-
related body functions and structures, sleep, hand and arm
use; self-care, household tasks, work and employment, and
leisure activities. Concepts of psycho-social functioning
and environmental factors were less frequently addressed.
Commonly used condition-specific measures showed a
large variation in content; the DASH and the ASES were
linked to more than twice as many ICF categories as the
Constant, SST and SPADI. These large differences demon-
strate the importance of clarifying the content to select the
most appropriate measure both in research and in clinical
work. For clinical situations, we propose use of a wide-
ranging condition specific measure that conceptualizes
assessments of shoulder pain from a bio-psycho-social
perspective. Further research is needed to investigate
whether patient-reported problems in functioning are
captured in the commonly used condition-specific and
generic measures.
Additional files
Additional file 1: Final search strategy for Medline.
Additional file 2: Overview of second-level ICF categories in the
most common multi-item measures.
Page 10 of 12
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
YR, HLS, EB-H and SO participated in the planning and design of the study.
YR developed a search strategy and collected the data. YR and SO
participated in the screening and linking. YR, SO, HLS and EB-H drafted the
manuscript. All authors read and approved the manuscript.
Acknowledgements
The authors would like to thank Dr. Heinrich Gall and other members at the
ICF Research Branch in cooperation with the WHO Collaborating Centre for
the Family of International Classifications in Germany (at DIMDI), Nottwil,
Switzerland for technical consultation, support and help during the conduct
of the study. Special thanks to Research Librarian Marit Isaksen at Oslo
University Hospital – Ullevaal for counselling in the development of a search
strategy and Kaia Engebretsen, Oslo University Hospital – Ullevaal for
participation in the screening and linking.
We certify that no party having a direct interest in the results of the research
supporting this article has or will confer a benefit on us or on any
organization with which we are associated and all financial and material
support for this research and work are clearly identified in the title page of
the manuscript.
Author details
1
Faculty of Health Sciences, Oslo and Akershus University College of Applied
Sciences, Postboks 4 Street Olavs plass, Oslo 0130, Norway. 2Department of
Physical Medicine and Rehabilitation, Oslo University Hospital Ulleval, Oslo,
Norway. 3Faculty of Medicine, University of Oslo, Oslo, Norway.
Received: 4 July 2012 Accepted: 19 February 2013
Published: 28 February 2013
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doi:10.1186/1471-2474-14-73
Cite this article as: Roe et al.: A systematic review of measures of
shoulder pain and functioning using the International classification of
functioning, disability and health (ICF). BMC Musculoskeletal Disorders
2013 14:73.

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II
J Rehabil Med 2013 Epub ahead of print

ORIGINAL REPORT

IDENTIFICATION OF RELEVANT INTERNATIONAL CLASSIFICATION OF

FUNCTIONING, DISABILITY AND HEALTH CATEGORIES IN PATIENTS WITH
SHOULDER PAIN: A CROSS-SECTIONAL STUDY

Yngve Roe, MSc1,3, Erik Bautz-Holter, PhD2,3, Niels Gunnar Juel, MSc2 and
Helene Lundgaard Soberg, PhD1,2
From the 1Faculty of Health Sciences, Oslo and Akershus University College of Applied Sciences,
2
Department of Physical Medicine and Rehabilitation, Oslo University Hospital Ulleval and 3Faculty of Medicine,
University of Oslo, Oslo, Norway

Objective: To identify the most common problems in patients population cohort, pain in the neck or shoulder during the
ZLWKVKRXOGHUSDLQXVLQJWKH,QWHUQDWLRQDO&ODVVL¿FDWLRQRI previous month was the most common health complaint, and
Functioning, Disability and Health (ICF) as a reference. DOPRVW WKUHHTXDUWHUV UHSRUWHG ZRUNUHODWHG SDLQ  0DQ\
Design: A cross-sectional study. cases of shoulder pain are persistent or recurrent, and shoulder
Subjects: Outpatients at a hospital with shoulder pain lasting SDLQLVDFRPPRQFDXVHRIZRUNDEVHQWHHLVP
longer than 3 months. The disability associated with shoulder pain has traditionally
Methods: Patients were interviewed with an extended ver- EHHQH[SODLQHGE\GH¿FLWVLQPXVFXODUDQGPRYHPHQWUHODWHG
sion of the ICF Checklist version 2.1a. Patients’ problems IXQFWLRQV)LQGLQJVIURPPRUHUHFHQWUHVHDUFKKRZHYHU
in functioning, and the magnitude of the problem, were reg- indicate that the condition may also have an impact on mental
LVWHUHG VHSDUDWHO\ IRU HDFK FDWHJRU\ &DWHJRULHV LGHQWL¿HG
IXQFWLRQ DQG JHQHUDO KHDOWK ± 0RUHRYHU SK\VLFDO DQG
as a problem in at least 5% of patients were reported. To
social factors in the work environment have been found to
describe the population, age, diagnosis, work participation
and the Shoulder Pain and Disability Index (SPADI) were
recorded.
Results: A total of 165 patients with a mean age of 46.5
years (standard deviation 12.5) and a SPADI score of 47.4
(standard deviation 21.1) were included. Of the participants,
92.8% were either employed or students, 35.2% of whom
LQÀXHQFH IXQFWLRQLQJ ±$OWKRXJK SUHYLRXV UHVHDUFK
provides a valuable contribution to the understanding of the
impact of shoulder pain on functioning, it has often been
OLPLWHG WR GH¿QHG SDWLHQWV JURXSV UHKDELOLWDWLRQ VHWWLQJV RU
VSHFL¿FDVSHFWVRIIXQFWLRQLQJ$QXPEHURIGLIIHUHQWFODVVL-
¿FDWLRQVDUHLQXVHDQGQRPXOWLGLVFLSOLQDU\FOLQLFDOSUDFWLFH
ZHUHRQVLFNOHDYH7KHSULPDU\UHVXOWZDVWKHLGHQWL¿FDWLRQ JXLGHOLQHVH[LVW±
RIFRQGLWLRQVSHFL¿FVHFRQGOHYHO,&)FDWHJRULHVLQWKH $VDUHVXOWRIWKHDSSURYDORIWKH,QWHUQDWLRQDO&ODVVL¿FDWLRQ
body functions and structures component, 34 in activities of Functioning, Disability and Health (ICF) in 2001, a system
and participation, and 8 in environmental factors. RIFRQFHSWVDQGDFODVVL¿FDWLRQRIIXQFWLRQLQJEHFDPHDYDLODEOH
Conclusion: 7KH ¿QGLQJV SURYLGH D FRPSUHKHQVLYH SLFWXUH
from the patient-perspective of the disability associated with
VKRXOGHUSDLQ7KH¿QGLQJVPD\HQKDQFHPXOWLGLVFLSOLQDU\
communication in clinical settings.
Key words: ICF; outcome assessment (health care); shoulder
7KH,&)SURYLGHVDKLHUDUFKLFDOFODVVL¿FDWLRQV\VWHPEDVHG
RQFRPSRQHQWVFKDSWHUVDQGFDWHJRULHV7KHbody functions and
structures component is ordered according to body regions or
systems, and the activities and participation component covers
the complete range of domains, denoting aspects of functioning
pain; cross-sectional studies, disability evaluation; World IURP ERWK DQ LQGLYLGXDO DQG D VRFLHWDO SHUVSHFWLYH  7KH
Health Organization; recovery of function; rehabilitation/cl environmental factors component is systematically arranged
>FODVVL¿FDWLRQ@UHKDELOLWDWLRQ in sequence from the individual’s most immediate environ-
J Rehabil Med 2013; 45: 00–00 ment to the general environment and may affect all functional
FRPSRQHQWVPersonal factors DUHQRWFODVVL¿HGLQWKH,&)
Correspondence address: Yngve Roe, Faculty of Health EHFDXVH RI WKHLU ZLGH VRFLDO DQG FXOWXUDO YDULDQFH  7KH
Sciences, Oslo and Akershus University College of Applied
ICF describes situations with regard to human functioning, and
Sciences, Postboks 4 St Olavs plass, NO-0130 Oslo, Norway.
E-mail: yngve.roe@hioa.no VHUYHVDVDIUDPHZRUNWRRUJDQL]HLQIRUPDWLRQ
7KH,&)FODVVL¿FDWLRQLVFRPSUHKHQVLYHDVLWFRPSULVHVPRUH
Accepted Feb 7, 2013; Epub ahead of print Maj 17, 2013 WKDQFDWHJRULHV7RLQFUHDVHLWVDSSOLFDELOLW\LQFOLQLFDO
DVVHVVPHQWVDQGUHVHDUFK,&)&RUH6HWVKDYHEHHQGHYHORSHG
The Core Sets contain a selection of categories that describe
INTRODUCTION
the typical spectrum of problems in functioning of patients
Shoulder pain is a common condition, with an estimated preva- ZLWKVSHFL¿FFRQGLWLRQV7KHGHYHORSPHQWSURFHVVHVZHUH
OHQFHRIEHWZHHQDQG,QD1RUZHJLDQPLGGOHDJHG based on literature reviews, expert surveys and quantitative

© 2013 The Authors. doi: 10.2340/16501977-1159 J Rehabil Med 45

Journal Compilation © 2013 Foundation of Rehabilitation Information. ISSN 1650-1977
2 Y. Roe et al.

DQGTXDOLWDWLYHFOLQLFDOVWXGLHVRISDWLHQWV&XUUHQWO\,&) ate, severe or complete$GGLWLRQDORSWLRQVRQWKH,&)TXDOL¿HUVVFDOH

Core Sets for a number of chronic conditions and settings are were 8 (QRWVSHFL¿HG), 9 (not applicable) and C (comorbidity7KHnot
VSHFL¿HGoption was avoided, and not applicable was registered only
DYDLODEOHHJORZEDFNSDLQDQGYRFDWLRQDOUHKDELOLWDWLRQ
for mutually exclusive categories in the major life areasGFKDSWHU
$VSDUWRIWKHGHYHORSPHQWSURFHVVSDWLHQWV¶SUREOHPVLQ &RPRUELGLW\ZDVUHJLVWHUHGRQDVHSDUDWHIRUP
IXQFWLRQLQJZHUHLQYHVWLJDWHGLQFURVVVHFWLRQDOVWXGLHV The case record form for patients contained both the Shoulder Pain
Until now, shoulder pain has rarely been investigated within the and Disability Index (SPADI) and the Self-Administered Comorbidity
bio-psycho-social perspective, and to our knowledge, there are 4XHVWLRQQDLUH6&47KH63$',LVDSDWLHQWUHSRUWHGFRQGLWLRQVSHFL¿F
instrument comprising 13 items in the pain and disability domains (29,
QRFRQGLWLRQVSHFL¿F,&)FDWHJRULHVIRUVKRXOGHUSDLQ 5DWLQJVDUHUHJLVWHUHGRQDQSRLQWRUGLQDOVFDOHIURPQRSDLQQR
The aim of this study was to identify the ICF categories that best GLI¿FXOW\WRZRUVWSDLQLPDJLQDEOHVRGLI¿FXOWLWUHTXLUHGKHOS
describe problems related to functioning and interactions with the A summed score ranging from 0 to 100 (best to worst) is estimated by
HQYLURQPHQWGXHWRVKRXOGHUSDLQIURPWKHSDWLHQW¶VSHUVSHFWLYH DYHUDJLQJWKHSDLQDQGGLVDELOLW\VXEVFRUHV7KH6&4LVDSDWLHQWUDWHG
instrument with a list of common health problems to which an additional
METHODS
Study design
This study had a cross-sectional design and included outpatients with
shoulder pain at the Department of Physical Medicine and Reha-
bilitation at Oslo University Hospital from November 2009 through
)HEUXDU\7KHVWXG\ZDVDSSURYHGE\WKH1RUZHJLDQ5HJLRQDO
Ethical Committee (number 2009/820a) and was conducted according
WRWKH'HFODUDWLRQRI+HOVLQNL
TXHVWLRQRQQHFNSDLQZDVDGGHG7KHUHVSRQGHQWZDVDVNHGWR
mark whether the health problem was present, whether treatment had
EHHQUHFHLYHGDQGZKHWKHUWKHSUREOHPOLPLWHGDFWLYLWLHV
Procedure
The outpatient clinic of the Department of Physical Medicine and
Rehabilitation at Oslo University Hospital receives patients with
musculoskeletal conditions who are referred from general practition-
HUV7KHSDWLHQWVXQGHUJRDQDVVHVVPHQWE\DSK\VLFLDQVSHFLDOL]LQJ
LQ SK\VLFDO PHGLFLQH %DVHG RQ VWDQGDUGL]HG FULWHULD D GLDJQRVLV
DFFRUGLQJWRWKH,QWHUQDWLRQDO&ODVVL¿FDWLRQRI'LVHDVHV,&'LV
Subjects PDGHDQGIXUWKHULQWHUYHQWLRQVDUHUHFRPPHQGHG
7KH LQFOXVLRQ RI WKH SDWLHQWV VKRZQ LQ )LJ  ZDV EDVHG RQ WKH
Patients aged 18 years and older, diagnosed with shoulder pain and
FRQWULEXWLRQV RI  SK\VLFLDQV DW WKH FOLQLF 7KH FOLQLF UHFHLYHV DS-
V\PSWRPVODVWLQJORQJHUWKDQPRQWKVZHUHHOLJLEOHIRUWKHVWXG\
proximately 750 patients with shoulder pain annually (personal com-
The exclusion criteria were shoulder joint replacement, surgery in the
PXQLFDWLRQ1*-3DWLHQWVZLWKDQDSSRLQWPHQWRQVSHFL¿FZHHNGD\V
affected shoulder within the last 6 months, diagnosed rheumatic disease
when the researcher (YR) would be present received a letter informing
DIIHFWLQJWKHVKRXOGHUJHQHUDOL]HGSDLQFRQGLWLRQVDQGLQVXI¿FLHQW
them about the study, and notifying them that they would be asked
1RUZHJLDQODQJXDJHVNLOOV
WRSDUWLFLSDWHDIWHUWKHFRQVXOWDWLRQLIWKH\PHWWKHLQFOXVLRQFULWHULD
Overall, 375 patients received information about the study, and 165
Measures
Data were collected with two sets of case record forms, one for health
SURIHVVLRQDOVDQGDQRWKHUIRUSDWLHQWV7KHFDVHUHFRUGIRUPIRUKHDOWK
professionals included registrations of the patients’ characteristics and the
nature of the patients’ work with regard to repetitive movements of the arm,
XVHRIWKHDUPDWRUDERYHVKRXOGHUOHYHODQGOLIWLQJNJRUPRUHDWZRUN
An extended ICF Checklist was derived for the patients from the ICF
FODVVL¿FDWLRQ7KHFDWHJRULHVLQWKH,&)FODVVL¿FDWLRQXVHDQDOSKDQX-
PHULFFRGLQJV\VWHPLQZKLFKWKH¿UVWOHWWHUUHIHUVWRWKHFRPSRQHQW
IROORZHGE\DQXPHULFFRGHWKDWVWDUWVZLWKWKHFKDSWHUQXPEHUHJ
SDWLHQWVZHUHLQFOXGHG7KHGLVWULEXWLRQRIJHQGHUDQGGLDJQRVHV
of the included patients were in accordance with the general cohort of
SDWLHQWVZLWKVKRXOGHUSDLQDWWKHFOLQLF
The included patients participated in a structured interview using the
case record form for health professionals and completed the case record
IRUPIRUSDWLHQWV7KHLQWHUYLHZVZHUHDGPLQLVWHUHGE\DSK\VLRWKHUD-
pist and researcher (YR) who has experience with the ICF and with
VKRXOGHUUHKDELOLWDWLRQLQFOLQLFDODQGHGXFDWLRQDOVHWWLQJV7KHUDWLQJV
of the severity of functional problems in the Extended ICF Checklist
ZHUHGHWHUPLQHGWKURXJKGLVFXVVLRQZLWKWKHSDWLHQW:KHQFDWHJRULHV
d4 mobilityIROORZHGE\WKHVHFRQGOHYHOFDWHJRU\HJGhand were not self-explanatory, examples from the inclusions of the ICF
and arm useWKHWKLUGOHYHOFDWHJRU\HJGreaching) and the ZHUH SURYLGHG )RU H[DPSOH WKH VHFRQGOHYHO FDWHJRU\ RIemotional
IRXUWKOHYHOFDWHJRU\ZKHQDSSURSULDWH functionsEZDVH[HPSOL¿HGE\joy, sorrow, tension, fear, anger,
The ICF Checklist in the current study was an extended version HWF7KHUDWLQJVRIVWUXFWXUDOLPSDLUPHQWZHUHEDVHGRQWKHVWDQGDUGL]HG
RI WKH JHQHULF ,&) &KHFNOLVW 9HUVLRQ D  7KH FRQWHQW RI WKH GLDJQRVWLFFULWHULD7KHPHDQGXUDWLRQZDVDSSUR[LPDWHO\
FRQGLWLRQVSHFL¿FVFDOHVDQGFOLQLFDOWHVWVZHUHH[WUDFWHGDQGOLQNHG PLQIRUWKHLQWHUYLHZVDQGPLQIRUWKHTXHVWLRQQDLUHV
WR ,&) FDWHJRULHV E\ D UHVHDUFKHU <5 WR HQVXUH WKDW DOO UHOHYDQW
IXQFWLRQVZHUHFRYHUHG7ZHQW\WKUHHDGGLWLRQDOVHFRQGOHYHO
FDWHJRULHVIURPWKHVHPHDVXUHVZHUHDGGHGWRWKHJHQHULFFKHFNOLVW Patients receiving information letter
7KH ¿QDO ([WHQGHG ,&) &KHFNOLVW FRQWDLQHG D WRWDO RI  VHFRQG n = 375
OHYHO,&)FDWHJRULHV2IWKHVHZHUHIURPWKH body functions and
structures component, 57 were from the activities and participation
component and 37 were from the environmental factorsFRPSRQHQW Patients not willing to participate
n = 176
The patients’ problems in each category were rated on an ordinal
VFDOHZLWKVFRUHVUDQJLQJIURPWR)RUWKH body functions
components, the scores included no impairment, mild impairment, Patients excluded:
moderate impairment, severe impairment and complete impairment Insufficient language skills: 20
For the body structures component, only the presence of impairment Diagnosis not related to shoulder: 14
n = 34
was rated, as either impairment or no impairment LQ WKLV VWXG\
In the activities and participation component, the categories were
denominated QRGLI¿FXOW\PLOGGLI¿FXOW\PRGHUDWHGLI¿FXOW\VHYHUH Patients included
GLI¿FXOW\ and FRPSOHWHGLI¿FXOW\ and were rated according to reported n = 165
SHUIRUPDQFH 7KH environmental factors component included both
barriers and facilitators of function, each categorized as mild, moder- Fig. 1.,QFOXVLRQSURFHGXUH

J Rehabil Med 45
 ICF categories in patients with shoulder pain 3

7DEOH,Characteristics of the patient population (n = 165) Statistical analysis

Characteristics 'HVFULSWLYH VWDWLVWLFV DUH XVHG WR FKDUDFWHUL]H WKH VWXG\ SRSXODWLRQ
Gender, educational level, employment status, primary ICD-10 diag-
Gender, male, % 46 nosis of the shoulder, comorbidity and the nature of the work were es-
Age, years, mean (SD) >±@ WLPDWHGDVUHODWLYHIUHTXHQFLHV$JHDQGWKH63$',WRWDOVXPPDU\
>UDQJH@ VFRUHZHUHHVWLPDWHGZLWKWKHPHDQDQGWKHVWDQGDUGGHYLDWLRQ6'
Education, % The relative frequencies (%) of ICF categories that registered as
”\HDUVLQVFKRRO 56 impairment, limitation, restriction, barrier or facilitator for at least 5%
University/college 44 RIWKHSDUWLFLSDQWVZHUHUHSRUWHGIRUHDFK,&)FRPSRQHQWVHSDUDWHO\
Employment status, % IBM SPSS Statistics, version 19 was used for the statistical analysis
Remuneratively employed  ,%0&RUSRUDWLRQ$UPRQN1<86$
Student in higher education 
Other 
Duration of pain, % RESULTS
3–6 months 15
6–12 months 26 The characteristics of the included patients and their comor-
> 12 months 59 ELGLWLHVDUHVKRZQLQ7DEOH,7KHUHZDVDVOLJKWRYHUUHSUHVHQWD-
Main ICD-10 diagnoses of the shoulder, % WLRQRIZRPHQ7KHGLDJQRVLVLPSLQJHPHQWV\QGURPH
P,PSLQJHPHQWV\QGURPHa  P ZDV WKH PRVW IUHTXHQW DFFRXQWLQJ IRU  RI WKH
P0\DOJLD 
P$GKHVLYHFDSVXOLWLV 
FDVHV$GGLWLRQDOQHFNSDLQZDVUHSRUWHGE\DOPRVWWZRWKLUGV
P,QVWDELOLW\  of the patients and low back pain was reported by more than
P5RWDWRUFXIIV\QGURPHb  RQHWKLUGRIWKHSDWLHQWV
P$FURPLRFODYLFXODUMRLQWUXSWXUHRUDUWKURVLV  :LWKUHJDUGWRHPSOR\PHQWVWDWXVRIWKHSDUWLFLSDQWV
Other diagnoses  ZHUHHLWKHUHPSOR\HGRUVWXGHQWVRIZKRPZHUHRQVLFN
Comorbidityc, %
Neck pain 66
OHDYH7KHUHPDLQGHURIWKHSDUWLFLSDQWVZHUHUHWLUHGXQ-
Back pain 35 HPSOR\HGUHFHLYHGGLVDELOLW\SHQVLRQRUZHUHKRPHPDNHUV7KH
Osteoarthritis (other than in shoulder) 14 nature of the work varied; 82% reported repetitive movements of
Depression 12 the arm, 29% reported frequent use of the arm at or above shoulder
Rheumatoid arthritis 4 OHYHODQGUHSRUWHGIUHTXHQWOLIWLQJRINJRUPRUHDWZRUN
Other medical conditions 37
SPADI total score, mean (SD)  7KHVHFRQGOHYHO,&)FDWHJRULHVWKDWZHUHLGHQWL¿HGDV
a problem in the body functions and structures component
a
,QFOXVLYHEXUVLWLVDQGSDUWLDOWKLFNQHVVWHDUV
b
2QO\IXOOWKLFNQHVVWHDUV
DUHVKRZQLQGHVFHQGLQJRUGHULQ7DEOH,,7KHPRVWIUHTXHQW
c
0RUHWKDQRQHFRPRUELGLW\ZDVUHJLVWHUHGLQVRPHSDUWLFLSDQWV problems were related to the sensation of pain (b280), mobil-
SD: standard deviation; SPADI: Shoulder Pain and Disability Index; ity of joint functions (b710), sleep (b134), muscle endurance
,&',QWHUQDWLRQDO&ODVVL¿FDWLRQRI'LVHDVHV±YHUVLRQ functions (b740) and energy and drive functionsE

7DEOH,,,QWHUQDWLRQDO&ODVVL¿FDWLRQRI)XQFWLRQLQJ'LVDELOLW\DQG+HDOWK,&)FDWHJRULHVRIWKHERG\IXQFWLRQVDQGVWUXFWXUHVFRPSRQHQWZLWK

relative frequencies (%), rated as impaired in at least 5% of participants
Body functions and structures categories 0 1 2 3 4 Sum 1–4
b280 Sensation of pain      
s720 Structure of shoulder region  – – – – 
b710 Mobility of joint functions      
b134 Sleep functions      
b740 Muscle endurance functions      
b130 Energy and drive functions      
b730 Muscle power functions      
b720 Mobility of bones function     0 
b840 Sensation related to the skin      
b735 Muscle tone functions      
b126 Temperament and personality functions     0 
b152 Emotional functions     0 
s730 Structure of upper extremity  – – – – 
b715 Stability of joint functions     0 
s710 Structure of head and neck region  – – – – 
b140 Attention functions     0 
b144 Memory functions     0 
b770 Gait pattern functions     0 
b164 Higher level cognitive functions    0 0 

J Rehabil Med 45
4 Y. Roe et al.

7DEOH,,,,QWHUQDWLRQDO&ODVVL¿FDWLRQRI)XQFWLRQLQJ'LVDELOLW\DQG+HDOWK,&)FDWHJRULHVRIWKHDFWLYLWLHVDQGSDUWLFLSDWLRQFRPSRQHQWZLWKUHODWLYH

frequencies (%), rated as a limited or restricted in at least 5% of participants
Activities and participation categories 0 1 2 3 4 Sum 1–4
d430 Lifting and carrying objects      
d850 Remunerative employment      
d920 Recreation and leisure      
d410 Changing basic body position      
d510 Washing oneself      
d540 Dressing      
d415 Maintaining a body position      
d640 Doing housework      
d620 Acquisition of goods and services     0 
d475 Driving      
d445 Hand and arm use      
d520 Caring for body parts     0 
d630 Preparing meals      
d465 Moving around using equipment      
d440 Fine hand use     0 
d770 Intimate relationships     0 
d530 Toileting     0 
d660 Assisting others     0 
d550 Eating    0 0 
d760 Family relationships     0 
d455 Moving around      
d750 Informal social relationships     0 
d740 Formal relationships     0 
d230 Carrying out daily routine     0 
d170 Writing     0 
d650 Caring for household objects    0 0 
d710 Basic interpersonal interactions     0 
d720 Complex interpersonal interactions     0 
d420 Transferring oneself     0 
d210 Undertaking a single task     0 
d730 Relating with strangers     0 
d220 Undertaking multiple tasks     0 
d470 Using transportation    0 0 
7KHKLJKHUHGXFDWLRQGFDWHJRU\ZDVOLPLWHGRUUHVWULFWHGLQRXWRIRIWKHSDWLHQWVUHJLVWHUHGDVVWXGHQWV

With respect to problems in the activities and participa-
tion  VHFRQGOHYHO ,&) FDWHJRULHV WKDW ZHUH LGHQWL¿HG DV
D SUREOHP DUH VKRZQ LQ GHVFHQGLQJ RUGHU LQ 7DEOH ,,, 7KH
most frequent problems were related to lifting and carrying
objects (d430), remunerative employment (d850), recreation
The 8 second-level ICF categories of the environmental factors
FRPSRQHQWLGHQWL¿HGDVDEDUULHURUIDFLOLWDWRUDUHVKRZQLQGH-
VFHQGLQJRUGHULQ7DEOH,91RFDWHJRULHVH[FHHGHGDIUHTXHQF\RI
Immediate family and friends (e310 and e320) were the most
frequently reported facilitators, while social security services, sys-
and leisure (d920) and changing basic body positions G tems and policiesHZDVWKHPRVWIUHTXHQWO\UHSRUWHGEDUULHU
2IWKHSDWLHQWVZKRZHUHVWXGHQWVUHSRUWHGGLI¿FXOWLHVLQ The distribution of categories according to ICF chapter-level
the higher education categoryGQRWVKRZQLQ7DEOH,,, LQ )LJ  VKRZV WKDW WKH KLJKHVW QXPEHU RI FDWHJRULHV ZHUH

7DEOH,9,QWHUQDWLRQDO&ODVVL¿FDWLRQRI)XQFWLRQLQJ'LVDELOLW\DQG+HDOWK,&)FDWHJRULHVRIWKHHQYLURQPHQWDOIDFWRUVFRPSRQHQWZLWKUHODWLYH

frequencies (%), rated as a barrier or facilitator in at least 5% of participants
Barrier Facilitator
Sum Sum
Environmental factors categories 0 –1 –2 –3 –4 (1–4) 1 2 3 4 (1–4)
e310 Immediate family    0 0     0 
e320 Friends  0 0 0 0 0    0 
e570 Social security services, systems and policies     0     0 
e125 Products and technology for communication     0     0 
e325 Acquaintances, peers, colleagues, neighbours
and community members     0    0 0 
e330 People in positions of authority     0    0 0 
e355 Health professionals    0 0    0 0 
e450 Individual attitudes of health professionals     0    0 0 

J Rehabil Med 45
 ICF categories in patients with shoulder pain 5

10
9
8

Number of categories
7
6
5
4
3
2
1
0

Fig. 2. 2YHUYLHZRI,QWHUQDWLRQDO&ODVVL¿FDWLRQRI)XQFWLRQLQJ'LVDELOLW\DQG+HDOWK,&)FKDSWHUVFRQWDLQLQJRQHRUPRUHVHFRQGOHYHOFDWHJRULHV

LGHQWL¿HGDVDIUHTXHQWSUREOHPEDUULHURUIDFLOLWDWRUn 

LGHQWL¿HGLQWKHFKDSWHUVRImobility (d4), with 10 categories, Furthermore, 7 categories related to problems of neuromus-

followed by the neuromusculoskeletal and movement-related culoskeletal and movement-related functions (b7) were identi-
functions (b7), mental functions (b1) and interpersonal inter- ¿HG2IWKHVHWKHPRVWIUHTXHQWO\UHSRUWHGSUREOHPVZHUHLQWKH
actions and relationships (d7) chapters, with seven categories mobility of joint functions (b710), muscle endurance functions
each, and self-care (d5), domestic life (d6) and support and (b740), muscle power functions (b730) and mobility of bone
relationshipsHFRPSULVLQJFDWHJRULHVHDFK functions E 0RVW RI WKHVH FDWHJRULHV UHÀHFW IXQFWLRQV
that are considered key elements in the clinical examination
DISCUSSION
7KHSULPDU\UHVXOWRIWKLVVWXG\ZDVWKHLGHQWL¿FDWLRQRIDVHW
RIVHFRQGOHYHO,&)FDWHJRULHVUHÀHFWLQJFRPPRQSUREOHPV
RIVKRXOGHUSDLQ7KH¿QGLQJVRIWKHFXUUHQWVWXG\WKXV
show that patients have perceptions of aspects of functioning
WKDW WUDGLWLRQDOO\ KDYH EHHQ DVVHVVHG E\ FOLQLFLDQV +RZHYHU
one of the frequent functions, muscle endurance, has received
in functioning and environmental factors in chronic shoulder
SDLQIURPWKHSDWLHQWV¶SHUVSHFWLYH
The characteristics of the patients show that patients in the
current study had a distribution of gender, age and diagnoses
that paralleled a sample of patients in a general practice report-
OHVVDWWHQWLRQLQWKHFOLQLFDOOLWHUDWXUH%UR[DQGFROOHDJXHV
found that isometric muscle endurance was associated with both
emotional distress and increased pain in a group of patients
with rotator cuff tendinosis, and they recommended muscle
endurance testing as a psychophysiological measure in assess-
HGE\YDQGHU:LQGWDQGFROOHDJXHV7KHPHDQ63$',WRWDO PHQWV7KH¿QGLQJVLQGLFDWHWKDWSDWLHQWVKDYHSHUFHSWLRQVRI
score did not deviate substantially from the scores reported by aspects of functioning that are often assessed by clinicians, and
Beaton and colleagues in a hospital-treated sample of patients IXWXUHUHVHDUFKVKRXOGLQYHVWLJDWHWKHEHQH¿WVRIWKHLPSURYHG
with shoulder-related diagnoses, or from a study by Ostor and SDUWLFLSDWLRQRISDWLHQWVLQWKHH[DPLQDWLRQV
FROOHDJXHVRQSDWLHQWVLQSULPDU\FDUH
Problems in functioning that related to a total of 19 catego-
ries in the body functions and structures component are shown
LQ7DEOH,,7KHsensation of pain (b280) was a problem for
almost all of the patients, and more than half of the patients
7KUHHFDWHJRULHVZHUHLGHQWL¿HGZLWKLQWKHbody structures
component, of which the structure of shoulder region (s720)
ZDV WKH PRVW IUHTXHQWO\ UHSRUWHG 7KH UHJLVWUDWLRQV ZHUH
made according to the evidence-based diagnostic criteria of
symptom localization and imaging used in the department (32,
rated their pain as severe or complete7KHIUHTXHQF\HVWLPDWH $OPRVWWZRWKLUGVRIWKHSDWLHQWVUHSRUWHGDGGLWLRQDOQHFN
and severity ratings show that pain itself is a major issue in the pain, and more than one-third reported additional low back
XQGHUVWDQGLQJRIVKRXOGHUSDLQ3DLQKDVDOVREHHQIRXQGWREH SDLQ 2WKHUV KDYH VKRZQ WKDW DGGLWLRQDO SDLQ RU V\PSWRP
an almost equally prevalent problem in other musculoskeletal VLWHVPD\EHSUHGLFWLYHIRUSDWLHQWV¶GLVDELOLW\&XQQLQJKDP
GLVRUGHUVVXFKDVORZEDFNSDLQ and colleagues (38) suggested that persons with multiple pain

J Rehabil Med 45
6 Y. Roe et al.
sites were more likely to report disability, while Kamaleri and
colleagues (39)found an almost linear relationship between
the number of pain sites and overall health, sleep quality,
DQGSV\FKRORJLFDOKHDOWK:KHWKHUSDLQLQWKHQHFNVKRXOGEH
FRQVLGHUHGDFRPRUELGLW\LVKRZHYHUDPDWWHURIGH¿QLWLRQ
ZKLFKKDVEHHQKDQGOHGGLIIHUHQWO\LQGLIIHUHQWVWXGLHV+RZ-
ever, we believe that only a few patients in the current study
may be characterized as having multiple pain sites because
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In the area of mental functions (b1-chapter), problems
and indicate that for some patients their shoulder pain has con-
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and behavioural factors in shoulder and neck pain, Linton (11)
suggested that a better understanding of these factors might
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almost equal number of low frequent functional problems in
the interpersonal interactions and relationships (d7-chapter)
were found among the other musculoskeletal conditions (24),
and problems in intimate relationships (d770) were found to
represent a common problem in all musculoskeletal ICF Core
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participants had problems with sleep (b134), energy and drive A large majority of the working patients reported problems
functions (b130) and temperament and personality functions with remunerative employment (d850), and 6 of 10 of the stu-
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factors have been found to be important in understanding the WLRQVKLSEHWZHHQVKRXOGHUSDLQDQGZRUN0RUHRYHUWKH
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der Windt and colleagues (40) found that these factors were parallel to the other cross-sectional study on musculoskeletal
more strongly associated with persistent pain and disability in FRQGLWLRQV,QDUHFHQWFURVVVHFWLRQDOVWXG\RQSDWLHQWV
patients with low back pain than in those with shoulder pain, in vocational rehabilitation, 40 activities and participation
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With regard to problems in activities and participation,
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(d4-chapter), problems in lifting and carrying objects (d430)
Problems in recreation and leisure (d920) were reported
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sports, playing, and engaging in handicrafts, hobbies and gath-
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and changing or maintaining a body position (d410 and d415) VKRXOGHU SDLQ  3UREOHPV LQ UHFUHDWLRQ DQG OHLVXUH ZHUH
ZHUHWKHPRVWFRPPRQO\UHSRUWHG:KHQFRPSDULQJWKHG also reported by patients with low back pain and also found
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sectional studies, lifting and carrying appeared to be a func- FRQGLWLRQV
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Unlike shoulder pain, problems walking were also frequent
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the self-care (d5) and domestic life (d6), problems in washing
oneself (d510), dressing (d540), doing housework (d640) and
acquisition of goods and services (d620) were the most fre-
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Eight environmental factorsZHUHLGHQWL¿HGDVIDFLOLWDWRUV
RUEDUULHUVWRIXQFWLRQLQJLQWKHFXUUHQWVWXG\)LYHRIWKH
categories were in support and relationships (e3-chapter) and
ZHUHSULPDULO\UHSRUWHGDVIDFLOLWDWRUV7KH¿QGLQJVRIUHOHYDQW
environmental factors in the current study indicate that social
factors may positively contribute to functioning for patients
ZLWKVKRXOGHUSDLQ$OWKRXJKHQYLURQPHQWDOIDFWRUVKDYHJHQ-
erally received little attention in shoulder pain research, there
been considered important and are thus often implemented in LVVRPHHYLGHQFHWRVXSSRUWWKHFXUUHQW¿QGLQJV±7KH
WKHLWHPVRIFRQGLWLRQVSHFL¿FVFDOHV%\FRQWUDVW cross-sectional study on musculoskeletal conditions also found
for low back pain, no frequent functions related to self-care, few and low frequency categories according to the component
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life functions were added during the development of the ICF development process for these conditions, indicating that
Core Set for low back pain, and these functions are also present structured interviews with limited time frames may not be the
LQWKHRWKHUPXVFXORVNHOHWDO&RUH6HWV PRVWDGHTXDWHPHWKRGWRLGHQWLI\WKHVHIDFWRUV
Although problems in social participation were reported by The ICF chapters registered with the highest number of func-
less than 20% of the patients, 7 functions of interpersonal inter- WLRQDOSUREOHPVDUHVKRZQLQ)LJ7KH¿QGLQJLOOXVWUDWHVWKH
actions and relationshipsGFKDSWHUZHUHLGHQWL¿HG7KHVH complexity of the disability associated with chronic shoulder
primarily concerned intimate relationships (d770), family pain, and underscores the need to address a number of different
relationships (d760) and informal social relationships (d750), IXQFWLRQDOGRPDLQVLQFOLQLFDOGHFLVLRQPDNLQJ

J Rehabil Med 45

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time, a comprehensive overview of functioning in shoulder
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example, the handling stress and other psychological demands
(d240) category occurred frequently in the vocational rehabili-
tation study, but it was not found in the measures used to extend
ICF categories in patients with shoulder pain 7
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associated with sixteen common shoulder diagnoses: a study of
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patients and patients with rheumatic disorders were included in Ring D, Kadzielski J, Fabian L, Zurakowski D, Malhotra LR,
the current study, even though shoulder pain may be common -XSLWHU-%6HOIUHSRUWHGXSSHUH[WUHPLW\KHDOWKVWDWXVFRUUHODWHV
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patients may not be representative of the general population of
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overview of disability in shoulder pain from the perspective of
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ICF categories from the components of body functions and
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relevant environmental factors in middle-aged patients with
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pain: a review on magnitude, risk factors, biochemical character-
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Classifying the forest or the trees? J Clin Epidemiol 2003; 56:
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ACKNOWLEDGEMENTS
The authors would like to thank the participants in this study and the staff
working at the outpatient clinic of the Department of Physical Medicine
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III
IV
RESEARCH ARTICLE
Development and Reliability of a Clinician-rated
Instrument to Evaluate Function in Individuals
with Shoulder Pain: A Preliminary Study
Yngve Roe1*, Benjamin Haldorsen2, Ida Svege3 & Astrid Bergland1
1
Faculty of Health Sciences, Oslo and Akershus University College of Applied Sciences, Oslo, Norway
2
Department of Physiotherapy, Martina Hansen’s Hospital, Bærum, Norway
3
Norwegian research center for Active Rehabilitation (NAR), Oslo, Norway

Abstract
Background and Purpose. Subacromial impingement syndrome (SIS) is a common and disabling condition in the
population. Interventions are often evaluated with patient-rated outcome measures. The purpose of this study was
to develop a simple clinician-rated measure to detect difficulties in the execution of movement-related tasks among
patients with subacromial impingement syndrome. Method. The steps in the scale development included a review
of the clinical literature of shoulder pain to identify condition-specific questionnaires, pilot testing, clinical testing
and scale construction. Twenty-one eligible items from thirteen questionnaires were extracted and included in a
pilot test. All items were scored on a five-point ordinal scale ranging from 1 (no difficulty) to 5 (cannot perform).
Fourteen items were excluded after pilot testing because of difficulties in standardization or other practical
considerations. The remaining seven items were included in a clinical test-retest study with outpatients at a hospital.
Of these, four were excluded because of psychometric reasons. From the remaining three items, a measure named
Shoulder Activity Scale (summed score ranging from 3 to 15) was developed. Results. A total of 33 men and 30
women were included in the clinical study; age range 27–80 years. The intraclass correlation coefficient results
for inter-rater reliability and test-retest reliability were 0.80 (95% CI = 0.51–0.90) and 0.74 (95% CI = 0.58–0.84),
respectively. The standard error of measurement and minimal detectable change were 1.19 and 3.32, respectively.
The scale was linked to the International Classification of Functioning, Disability and Health second level categories
lifting and carrying objects (d430), dressing (d540), hand and arm use (d445) and control of voluntary movement
(b760). Conclusion. The Shoulder Activity Scale showed acceptable reliability in a sample of outpatients at a
hospital, rated by clinicians experienced in shoulder rehabilitation. The validity of the scale should be investigated
in future studies before application to common practice. © 2013 The Authors. Physiotherapy Research Interna-
tional published by John Wiley & Sons Ltd.

Received 21 October 2011; Revised 5 September 2012; Accepted 5 April 2013

*Correspondence
Yngve Roe, MSc, Faculty of Health Sciences, Oslo and Akershus University College of Applied Sciences, Postboks 4 St. Olavs plass, 0130
Oslo, Norway.

E-mail: yngve.roe@hf.hio.no

Published online in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/pri.1555

Physiother. Res. Int. (2013) © 2013 The Authors. Physiotherapy Research International published by John Wiley & Sons Ltd.
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,
provided the original work is properly cited.
The Shoulder Activity Scale
Introduction
Shoulder pain is an umbrella term for conditions with
different aetiologies and courses, and prevalence estimates
have varied between 7% and 26% (Luime et al., 2004, van
der Heijden, 1999). Subacromial impingement syndrome
(SIS) is probably the most common shoulder diagnosis,
and the condition is associated with substantial loss of
function (Neumann, 2010, Silva et al., 2008, Lewis et al.,
2005, van der Windt et al., 1995). SIS is describing a
dysfunctional mechanism, and the alterations in move-
ment patterns associated with the condition have been
extensively analysed (Bigliani and Levine, 1997, Michener
et al., 2003, Neumann, 2010, Lin et al., 2006, Ludewig and
Cook, 2000, Lukasiewicz et al., 1999). It is essential that the
alterations in movement patterns are also included in
functional assessments in the clinic, but few such
standardized measures are available.
Reliable and valid standardized measures are important
for clinical decision making and research. Patient-rated
outcome measures have been recommended to evaluate
interventions in patients with shoulder pain, and a num-
ber of condition-specific measures are now available
(Bot et al., 2004, Michener, 2011). Clinician-rated
methods are also considered important in assessments,
but the most commonly used measures are either a
standardization of the clinical examination or physical
examination tests (Constant and Murley, 1987, Richards
et al., 1994, Hegedus et al., 2008). Although the patient-
rated and clinician-rated condition-specific measures
probably capture different aspects of functioning, few
efforts have been made to analyse the content.
The International Classification Of Functioning,
Disability and Health (ICF), provides a framework for
describing and classifying the content of all measures
of function (WHO, 2001). The ICF is based on an
integrative model covering functioning within its
components of body functions (b), body structures (s),
activities and participation (d) and the environmental
(e) and personal factors (not classified). The ICF classi-
fication provides categories of functioning and envi-
ronmental factors that are arranged in a hierarchical
fashion by using an alphanumeric coding system; the
first letter referring to the component, followed by a
numeric code that starts with the chapter number
(e.g. mobility, d4-chapter), followed by the second level
(e.g. hand and arm use, d445), third level (e.g. reaching,
d4452) and fourth level when appropriate. Because of a
generic structure, the categories at a lower level are
included in the higher level categories and chapters.
Procedures have been established to classify the content
Physiother. Res. Int. (2013) © 2013 The Authors. Physiotherapy Research International published by John Wiley & Sons Ltd.
Y. Roe et al.
of functional measures by ICF categories, regardless of
their purpose, extent and by whom they are rated
(Cieza et al., 2002, Cieza et al., 2005).
According to the ICF, the traditional clinician-rated
measures may be referred to as belonging to the body
functions and structures components, whereas the
available patient-rated questionnaires to the activities
and participation (Michener, 2011). To our knowledge,
no clinician-rated measure containing content relating
to the activities & participation component of the ICF
has been developed. The clinician-rated measures have
the advantage of directly measuring the unit of interest;
they reflect the current situation and are less vulnerable
to the patient’s recall, language and problems with
vision or literacy (Gotay, 1996). Patient and clinician
ratings probably reflect different constructs, and a low
to moderate correlation has been reported (Reneman
et al., 2002, Mannerkorpi et al., 2006, Stratford and
Kennedy, 2006). The aim of this study was to develop
a reliable clinician-rated functional scale to measure
change over time, according to the ICF component
activities and participation, in patients with SIS.
Methods
Scale development
The steps in the scale development included a review of
the scientific literature of shoulder pain, pilot testing,
clinical testing and scale construction (Clark and Watson,
1995, Loevinger, 1957, Streiner and Norman, 2008)
(Figure 1). Thirteen frequently used condition-specific
questionnaires of shoulder function were identified after
a review of the scientific literature. From these, 21 single
items were extracted and considered eligible for pilot test-
ing after discussions between the researchers (YR, BH and
IS). All items described the execution of tasks with
dynamic movements of the arm at or above shoulder level.
With the participation of outpatients with shoulder pain at
a hospital, the eligible items were further investigated in a
pilot test. The researchers (BH and IS) and other
experienced physiotherapists at the hospital participated
as observers. As a result of the pilot test, 14 items that were
difficult to standardize or gave little information about the
patient’s movement patterns were excluded. Decisions
were based on agreement between all observers. In cases
of disagreement, a senior member of the research group
(AB) was consulted. There were no examples of such
disagreement. The remaining 7 items were included in a
full-scale clinical study for investigation of reliability and
representation in the ICF classification.
Y. Roe et al.
Items eligible
n = 21
Items for psychometric investigations
n=7
Items included in the final scale
n=3
Figure 1. Flowchart of the item reduction process
To rate the magnitude of a functional problem, a
five-point ordinal scale similar to the qualifiers in the
ICF classification was used (WHO, 2001). The anchor
points of the scale were no difficulty (1), mild difficulty
(2), moderate difficulty (3), severe difficulty (4) and
cannot perform (5). No definition of the term difficulty
was given, as it was assumed that physical therapists
experienced in shoulder rehabilitation have a common
understanding of the term. The intervals between the
categories were not further investigated but treated as
equal in the statistical analyses.
All items were linked to second level ICF categories
according to established rules (Cieza et al., 2005).
Inter-item and item-to-sum correlations and representa-
tion in the ICF classification were used as exclusion
criteria. A tentative summed scale named Shoulder Ac-
tivity Scale (SAS) was constructed from the remaining
three items and further statistically examined (Appendix
1). The included items were lifting an object to a shelf,
putting on a jacket and moving an arm sideways. All
items were weighted equal, and the scale had a possible
range of 3 (no difficulties) to 15 (cannot perform). The
scale was easy to administer and was in most cases
completed within 5 minutes. No adverse effects from
performing the SAS items were reported by the subjects
or identified by the raters.
The items were linked to the ICF second level
categories lifting and carrying objects (d430), dressing
(d540) and hand and arm use (d445), respectively.
The aim of the scale, to measure difficulty in terms of
altered movement patterns, was linked to the control
of voluntary movement (b760) category.
Subjects
A clinical test-retest study with outpatients attending the
orthopaedic division at a hospital between December
Physiother. Res. Int. (2013) © 2013 The Authors. Physiotherapy Research International published by John Wiley & Sons Ltd.
The Shoulder Activity Scale
Items excluded , pilot testing
n = 14
Items excluded , psychometric testing
n=4
2007 and October 2010 was conducted. The eligible
patients were non-native English speakers. Inclusion
criteria were primary diagnosis of SIS according to stan-
dardized criteria (Juel et al., 2008, Walker-Bone et al.,
2003). Exclusion criteria were systematic inflammatory
disease or generalized pain, cardiac disease, symptoms
of cervical spine disease or surgery in the affected shoul-
der within the last 6 months.
Power analysis
A method for sample size based on the intraclass correla-
tion coefficient (ICC), was chosen (Walter et al., 1998).
The minimally acceptable ICC value (r1 = 0.7) versus
an alternative ICC value reflecting the expectations
(r1 = 0.8) was chosen. With a power of 80% (b = 0.2)
and a significance level of 5%, a sample size of at least
40 patients was required (Walter et al., 1998).
Procedure and measures
Descriptive information was collected for all participants.
The items were tested twice for each participant without
any treatment in between. The instruction to the patients
was as far as possible provided in a standardized manner
and is shown in Appendix 1. The average time between
baseline test and retest was 7.5 days (range 7–21). The
participants were asked on the day of retest whether a
substantial change in their shoulder condition had
occurred since the baseline test. Participants were
included in the further analyses regardless of whether a
substantial change in their condition had occurred.
Two independent clinicians took part in the testing at
baseline, where one participated at retest. A total of five
clinicians participated in the test sessions; all experienced
in shoulder rehabilitation at the hospital. All clinicians
The Shoulder Activity Scale
had participated in a standardized training session before
conducting the test sessions.
Participants also completed the Shoulder Pain and
Disability Index (SPADI) at baseline test (Roach et al.,
1991). SPADI is a patient-rated measure for patients
with shoulder pain consisting of 13 questions, divided
in the domains pain (5 items) and disability (8 items).
Each item is rated on a numerical scale from 0 (best) to
10 (worst) and summed up to a domain score. Each
domain score is equally weighted then added for a total
percentage score ranging from 0 to 100.
Statistical analysis
The statistical analysis was conducted with the IBM SPSS
Statistics 19 for windows (IBM Corporation, New York,
USA) and the STATA/IC 11.1 for Mac (StataCorp LP,
Lakeway Drive, Texas, USA).
The mean values or frequencies with the standard
deviations (SD) were reported for the numerical or cate-
gorical variables. The association between the SAS scores
and age and duration of symptoms was investigated with
estimations with Pearson’s product–moment correlation
coefficient (r) and visual inspection of bivariate data for
non-linear relations.
For further investigation of reliability, the following
underlying measurement properties were chosen
(Mokkink et al., 2010, Terwee et al., 2007): internal consis-
tency, reliability and measurement error. Internal consis-
tency was estimated with Cronbach’s alpha. An alpha
between 0.7 and 0.9 was considered fair. Consistency
and unidimensionality was further investigated with
inter-item correlations estimated with Pearson’s prod-
uct–moment correlation coefficient (Cortina, 1993).
Inter-item correlations in the range of 0.15–0.50 and mean
inter-item correlations of 0.40–0.50 were considered accept-
able (Clark and Watson, 1995). Inter-rater reliability and
test-retest reliability was estimated with the ICC. To be able
to generalize the results to a population of other clinicians
and because the difficulty of the items was considered to
be a systematic source of variance, a two-way random
effect model single measure reliability had to be chosen
(Shrout and Fleiss, 1979, McGraw and Wong, 1996).
The measurement error was defined as the system-
atic and random error of a patient’s score that was
not attributed to true changes in the construct to be
measured (Mokkink et al., 2010). The standard error
of measurement (SEM), which reflects the standard
deviation of the distribution of the patient’s score, with
Physiother. Res. Int. (2013) © 2013 The Authors. Physiotherapy Research International published by John Wiley & Sons Ltd.
Y. Roe et al.
no change in health status and no learning effect taking
place, was used (Wyrwich, 2004, Weir, 2005). There
are two types of SEM: SEMagreement and SEMconsistency.
To take the systematic difference into account, the
SEMagreement was chosen, estimated with the formula
pffiffiffiffiffiffiffiffiffiffiffiffiffi
¼ sx 1  rtt , where (sx) was the pooled standard devia-
tion of test and retest scores, and (rtt) was the reliability co-
efficient. From the SEM value, it is possible to estimate the
minimal detectable change (MDC), which is the smallest
change that can be defined by the instrument beyond mea-
surement error (de Vet et al., 2006, Beckerman et al., 2001).
pffiffiffi
The following formula was used: MDC ¼ 1:96  2 
SEM, where 2 relates to test and retest, and 1.96 relates to
the 95% confidence interval. A plot with the difference
of the baseline and retest versus the mean of the sum
scores was drawn (Bland and Altman, 1999). The limits
of agreement (LOA) were plotted as the standard devia-
tion of the mean difference (SD) multiplied by 1.96.
All the participants signed a written consent, and the
study was approved by the Norwegian Regional
Committee for Ethics and conducted according to the
Helsinki Declarations.
Results
Sixty-three patients, thirty women and thirty-three men
participated in the clinical study. Ninety-four met the in-
clusion criteria, twenty-nine did not accept participation,
two were excluded because of generalized pain and three
dropped out between baseline test and retest. No descrip-
tive data were recorded on eligible patients who did not
accept participation. The mean age of the participants
was 53.3 years (SD = 12.9). The mean duration of symp-
toms was 46.6 months (SD = 72.3). Thirty-eight of the
participants were working, eight were sick listed and
seventeen were retired, receiving disability benefit or
unemployed. There were 30 cases of pain in the right
shoulder, 19 in the left shoulder and 14 cases of bilateral
pain. The dominant arm was affected in 30 of the cases.
Five patients reported a substantial change of the
condition during the test period. The mean SPADI score
at baseline was 36.2 (SD = 16.6).
The item-to-item correlations ranged between 0.30
and 0.49, and the item-to-total between 0.70 and 0.82
(Table 1). The Cronbach’s alpha of consistency for
the SAS sum score was estimated at a = 0.86. There
were no significant correlations or non-linear associa-
tions between the participants’ ages or permanence of
symptoms and the SAS score.
Y. Roe et al.
Table 1. Significant inter-item and item-to-sum correlations with
Pearson’s r in the baseline test scores (n = 63)
Putting on a Moving an arm Shoulder Activity
Item jacket sideways Scale sum score
Lifting an object 0.30 0.49
to a shelf
Putting on a 0.34
jacket
Moving an arm
sideways
The distribution of the scale were positively skewed
as two participants had an SAS score of 3 and none
above 12 (Figure 2).
The moving the arm sideways had a higher mean
score than the other items, indicating that it was a more
difficult task (Table 2).
The difference between SAS test and retest was plot-
ted against the average, with the 95% limits of agree-
ment at 2.72 and 3.79 (Figure 3). The mean
difference was 0.53. Three out of sixty values were
outside the LOA.
Discussion
The aim of this study was to develop a reliable
clinician-rated functional scale to measure change over
time, according to the ICF component activities and
participation, in patients with SIS.
The main results of the clinical study were the find-
ings of an inter-rater reliability and test-retest reliability
of the SAS of 0.80 and 0.74, respectively (Table 2), in
line with what was expected in the power analysis.
There is no commonly agreed limit for what should
be considered an acceptable ICC value, but an ICC
above 0.70 with the lower limit of the confidence inter-
val above 0.60 has been proposed in clinician-rated
methods (Terwee et al., 2006). Even though both reli-
ability estimates exceeded the minimum recommenda-
tions, the lower limits of the 95% confidence interval
for both estimates were slightly below 0.60. The accept-
able reliability found in the current study were in line
with previous findings of Westerberg and colleges
who concluded that three active motor tests had good
reliability when used as functional tests in painful
shoulders (Westerberg et al., 1996).
The inter-item correlations (Table 1) in the final scale
was within what was considered acceptable, ranging
from 0.30 to 0.49 (Clark and Watson, 1995). An internal
Physiother. Res. Int. (2013) © 2013 The Authors. Physiotherapy Research International published by John Wiley & Sons Ltd.
The Shoulder Activity Scale
0.77
0.70
0.82
Figure 2. Histogram with the distribution of Shoulder Activity
Scale sum scores at the baseline test (n = 63)
consistency of 0.88 indicates that no items were
redundant or measured other constructs. Other possible
combinations of items resulted in lower alpha values.
The three items were most likely not equally difficult
as the item moving an arm sideways had a higher mean
score (Table 2). However, the item had an acceptable
inter-item correlation and item-to-total correlation
(Table 1). The problems of different item-difficulty in
scales are shared with other scales developed through
statistical analysis based on classical test theory.
The MDC for the SAS was estimated to 3.30
(Table 2). The interpretation is that individual changes
in the sum score of 1–3 points can be due to systematic or
random errors. In classical test theory, the MDC is con-
sidered a stable property of the instrument, and a change
in the sum score of 4 or higher should thus be considered
real but not necessarily clinically relevant (de Vet et al.,
2006). The MDC should not be interchanged with the
minimal important difference, which refers to the benefit
of treatment in a specific population (de Vet et al., 2006,
de Vet and Terwee, 2010). Controversy exists whether the
benefit of treatment estimates should be derived from
distribution-based or anchor-based methods. Norman
and colleagues found consistent evidence that the minimal
important difference equals close to half of an SD at base-
line in a systematic literature review where both anchor-
based and distribution-based methods had been used
(Norman et al., 2003). Furthermore, Wyrwich suggested
The Shoulder Activity Scale
Table 2. Reliability estimates (n = 60) with pooled test-retest mean, range and inter-rater reliability, test-retest reliability, standard error of
measurement (SEM), minimal detectable change (MDC) and effect size for single items (1–5) and sum score (3–15)
Item Mean (SD) Range ICC inter-rater (95% CI)
Lifting an object to a shelf 1.87 (0.98) 1–5
Putting on a jacket 1.94 (0.98) 1–5
Moving an arm sideways 3.00 (1.15) 1–5
SAS sum score 6.81 (2.38) l3–12
a one-to-one relation between the minimal important
difference and the SEM (Wyrwich, 2004). Estimates based
on the aforementioned distribution-based methods
resulted in a minimal important difference of 1.19 in both
cases. According to the estimation methods recommended
by Norman and Wyrwich, an SAS sum score of at least 4 is
also clinically important.
The participants had a high functional level measured
with SPADI, compared with other studies including
patients with subacromial conditions (Ekeberg et al.,
2008, Williams et al., 1995). There were only two patients
with the lowest SAS score of 3, and none with the sum
scores 13–15 (Figure 2). Even though the distribution
was obviously skewed, this is less than the 15% normally
considered a floor effect (Terwee et al., 2007). A skewed
distribution however should not necessarily be consid-
ered a problem in functional scales but rather a common
and logical manifestation of the underlying construct
(Streiner and Norman, 2008). The LOA-plot (Figure 3)
gives a graphical expression of the ability of an
instrument to replicate observations, and the differences
should ideally be close to zero (Bland and Altman, 1999).
The plot gives a visual indication of a slightly higher
retest score among most participants, consistent for both
low and high SAS average scores.
Figure 3. Intra-individual differences (n = 60) plotted against the
difference between test and retest scores on Shoulder Activity
Scale. The central horizontal line represents the mean difference,
whereas the flanking lines represent the 95% limits of agreement
Physiother. Res. Int. (2013) © 2013 The Authors. Physiotherapy Research International published by John Wiley & Sons Ltd.
Y. Roe et al.
ICC test-retest (95% CI) SEM MDC
0.66 (0.35–0.82) 0.59 (0.40–0.73) 0.61 1.69
0.71 (0.42–0.85) 0.55 (0.35–0.71) 0.62 1.72
0.75 (0.61–0.84) 0.84 (0.75–0.90) 0.45 1.25
0.80 (0.51–0.90) 0.74 (0.58–0.84) 1.19 3.30
The items in SAS were linked to ICF categories from
the mobility (d4-chapter) or self-care (d5-chapter) of
the activities and participation component, and the
aim of the scale was linked to the neuromusculoskeletal
and movement-related functions (b7-chapter) of the
body functions component (WHO, 2001). To our
knowledge, no other similar clinician-rated activity
scale exists. The standardized clinical examination
methods and the physical examination tests commonly
used in the assessments have no content relating to the
activities and participation component of the ICF (Con-
stant and Murley, 1987, Hegedus et al., 2008, Richards
et al., 1994). The FiT-HaNSA-test focuses on muscle
endurance, which is also covered by the body functions
component (MacDermid et al., 2007). Hence, the test
probably measures a different construct than the SAS.
The SAS needs to be validated before implemented
into clinic. Nevertheless, the current study may con-
tribute to increase the attention on the content of func-
tional assessments in patients with shoulder pain. The
study may facilitate a further use of the ICF to classify
functional measures. Future work should further inves-
tigate how standardized clinician-rated measures may
be implemented in functional assessments and how
they relate to the patient-rated measures.
Study limitations
First, the SAS is based on the assumption that clinicians
have a common understanding of the term difficulty.
Although the assumption is supported by the findings
of the current study, it may have contributed that all
the raters were working at the same hospital. No com-
monly agreed on guidelines for assessments of shoulder
pain yet exists. Second, the treatment of ordinal data as
numerical in the statistical analyses may be questioned,
because no investigations of the intervals between the
anchor points had been conducted. The approach was
chosen because of the fact that most statistical methods
used in psychometric evaluations require numerical
Y. Roe et al.
data (Streiner and Norman, 2008). Third, it should be
recognized that the test was applied to a non-native
English-speaking population, and it is thus possible
that native English-speaking patients might interpret
the instructions differently.
Conclusions
The SAS seems to be a reliable clinician-rated instru-
ment to measure functional change in patients with
SIS. A change score of at least 4 points is required for
evaluation of individual patients. Time of administra-
tion was less than 5 minutes, and no specialized equip-
ment is required. The content of the scale is covered by
the mobility (d4-chapter) and self-care (d5-chapter) of
the ICF. The validity of the scale needs to be established
before it is applied to common practice.
Acknowledgements
We thank Gerty Lund and Ingrid Walter who contrib-
uted in the data collection, and all the patients who
participated in the study.
The study was supported by The Norwegian Fund for
Postgraduate Training in physiotherapy and Bergesens
Almennyttige Stiftelse (Bergesen’s Foundation).
We certify that no party having a direct interest
in the results of the research supporting this article
has or will confer a benefit on us or on any
organization with which we are associated and all
financial and material support for this research
and work are clearly identified in the title page of
the manuscript.
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WHO. International Classification of Functioning,
Disability and Health: ICF. Geneva: World Health
Organization, 2001.
Williams JW, Jr., Holleman DR, Jr., Simel DL. Measuring
shoulder function with the Shoulder Pain and Disability
Index. Journal of Rheumatology 1995; 22: 727–732.
Wyrwich KW. Minimal important difference thresholds
and the standard error of measurement: is there a
connection? Journal of Biopharmaceutical Statistics
2004; 14: 97–110.

Appendix 1. Shoulder Activity Scale

Score (circle the most relevant)

No Mild Moderate Severe Cannot

Test Procedure Instruction difficulty difficulty difficulty difficulty perform
1. Lifting an From a standing or sitting position, the subject Lift the object up on the 1 2 3 4 5
object to a shelf lifts a 1-kg object from a table to a high shelf. shelf and back on the table
The task is repeated three times without a three times.
break. The height of the shelf should be
slightly above the subject’s head, and the
difference in height between the table and
the shelf is at least 0.7 m.
2. Putting on a From a standing or sitting position, the Put on the jacket with the 1 2 3 4 5
jacket subject puts on a jacket with the healthy arm healthy arm in the first
in the first sleeve and then off beginning with sleeve and take it off with
the painful arm. The jacket should be medium the painful arm first.
tight and made of non-stretchy material.
3. Moving an From a sitting position, with approximately 90 Lift the object up from the 1 2 3 4 5
arm sideways angle in the hip and knee, the subject desk to shoulder height with
lifts a 2-kg object with a straight and a straight arm. Keep the
approximately 90 internal rotated upper body stable. Move the
arm, from a table in front and to object sideways until the
the height of the shoulder. The arm is arm is outside the shoulder,
now at 90 flexion, internal rotated in a and then back to forward
sagittal plane. The straight arm is abducted position. Keep the arm at
to the frontal plane, and adducted to the shoulder level and straight
sagittal plane without allowing through the movement.
any variation in the height or The task is repeated once
the rotation of the arm. The task is without a break.
repeated once without a break.
Sum-score 1 + 2 + 3 = ____ points

Physiother. Res. Int. (2013) © 2013 The Authors. Physiotherapy Research International published by John Wiley & Sons Ltd.
APPENDIXES
 omstendigheter, ofte benevnt eksekutive
Extended ICF Checklist funksjoner.
b167 Mentale språkfunksjoner
Spesifikke funksjoner for å gjenkjenne
og bruke tegn, symboler og andre
AVVIK I KROPPSFUNKSJONER bestanddeler av et språk.
MENTALE FUNKSJONER b2 SANSEFUNKSJONER OG SMERTE
b110 Bevissthetsfunksjoner b210 Synsfunksjoner
Grunnleggende funksjoner som Sanse lys og farge, og se størrelse, form
bestemmer bevissthetens klarhet og og avstand.
kontinuitet, oppmerksomhet og b230 Hørselsfunksjoner
aktsomhet. Sanse lyd og skille mellom lyders
b114 Orienteringsfunksjoner tonehøyde, styrke, egenart og sted.
Bevissthet om og kjennskap til forholdet b235 Vestibularisfunksjoner
til egen person, til andre personer, til tid Sanse kroppsstilling, balanse og
og omgivelser. bevegelse.
b117 Intellektuelle funksjoner b265 Berøringssans
Grunnleggende mentale funksjoner som Sanse overflater og deres struktur eller
må til for å forstå og konstruktivt egenart.
integrere de forskjellige mentale b280 Smertesans
funksjoner, herunder alle kognitive Sanse ubehagelige stimuli som tyder på
funksjoner og deres utvikling i løpet av mulig eller faktisk skade på kroppen.
livet. b3 STEMME- OG TALEFUNKSJONER
b126 Temperament og personlighet
Tendens til å reagere på bestemte måter b310 Stemmefunksjoner
i situasjoner, deriblant de mentale Funksjoner for å frembringe lyd ved
særtrekk som skiller individet fra andre passasjen av luft gjennom strupen.
personer. b4 KRETSLØPS-, BLOD-, IMMUN- OG
b130 Energi og handlekraft RESPIRASJONSFUNKSJONER
Grunnleggende mentale funksjoner
tilknyttet fysiologiske og psykiske b410 Hjertefunksjoner
mekanismer som fører til vedvarende Funksjoner for å pumpe blodet ut i
innsats for å tilfredsstille behov og oppnå kroppen i tilstrekkelig mengde og med
mål. passende trykk.
b134 Søvn b420 Blodtrykksfunksjoner
Periodisk, reversibel og selektiv fysisk og Regulering av arterielt blodtrykk.
mental frakobling fra ens umiddelbare b430 Blodfunksjoner og bloddannelse
omgivelser, ledsaget av karakteristiske Bloddannelse, transport av oksygen og
fysiologiske forandringer. stoffskifteprodukter, blødningsstillende
b140 Oppmerksomhetsfunksjoner funksjoner.
Funksjoner for å fokusere på ytre stimuli b435 Immunfunksjoner
eller indre opplevelser så lenge som det Forsvar mot fremmede substanser og
behøves. mikroorganismer.
b144 Hukommelsesfunksjoner b440 Respirasjon
Spesifikke kognitive funksjoner for Innånding av luft i lungene,
registrering, lagring og fremhenting av gassutveksling mellom luft og blod og
informasjon. utånding av luft.
b152 Emosjonelle funksjoner b5 FORDØYELSE, STOFFSKIFTE OG
Spesifikke funksjoner knyttet til følelser INDRESEKRETORISKE FUNKSJONER
og affektive komponenter i mentale b515 Fordøyelse
prosesser. Funksjoner for transport av mat og
b156 Persepsjonsfunksjoner drikke gjennom fordøyelseskanalen,
Spesifikke kognitive funksjoner for å nedbryting til næringsstoffer og
gjenkjenne og tolke det som sanses. oppsuging av næringsstoffene.
b164 Høyere kognitive funksjoner b525 Avføringsfunksjoner
Spesifikke mentale funksjoner som er Utskillelse av ufordøyet mat og
spesielt avhengige av hjernens avfallsprodukter fra tarmen, med
pannelapper: Sammensatte målrettede tilhørende funksjoner.
atferdsformer, som å ta beslutninger, b530 Regulering av kroppsvekt
abstrakt tankevirksomhet, planlegging og Herunder vektøkning under vekst og
gjennomføring av planer, mental utvikling.
fleksibilitet og å avgjøre hva slags atferd b555 Indresekretoriske funksjoner
som er hensiktsmessig under hvilke Hormonproduksjon og regulering av
 hormonspeil i kroppen, herunder sykliske AVVIK I KROPPSSTRUKTURER
forandringer.
b6 URINSYSTEMETS FUNKSJONER, s1 NERVESYSTEMETS
KJØNNSFUNKSJONER OG STRUKTURER
FORPLANTNING s110 Hjernens struktur
b620 Vannlatingsfunksjoner s120 Ryggmargen og tilhørende
Funksjoner for uttømming av urin fra strukturer
urinblæren.
b640 Kjønnsfunksjoner s4 STRUKTURER TILHØRENDE
Psykiske og fysiske funksjoner med KRETSLØPSSYSTEMET,
tilknytning til kjønnsakten, herunder BLODSYSTEMET, DET
seksuell opphisselse (eksitasjonsfase), IMMUNOLOGISKE SYSTEM OG
funksjoner under selve kjønnsakten RESPIRASJONSSYSTEMET
(platåfase), utløsning (orgasme) og s410 Kretsløpssystemets struktur
påfølgende avspenning s430 Respirasjonssystemets struktur
(resolusjonsfase). s6 STRUKTURER MED
b7 NERVE-, MUSKEL-, SKJELETT- OG TILKNYTNING TIL
BEVEGELSESRELATERTE URINSYSTEMET,
FUNKSJONER KJØNNSORGANENE OG
b710 Leddbevegelighet FORPLANTNINGEN
Bevegelsesutslag og bevegelsesfrihet i s610 Urinsystemets struktur
ledd. s630 Kjønnsorganenes strukturer
b715 Leddstabilitet s7 BEVEGELSESAPPARATETS
Opprettholdelse av leddenes strukturelle STRUKTURER
forbindelse. s710 Hode- og halsregionens struktur
b720 Knokkelbevegelighet s720 Skulderregionens struktur
Bevegelsesutslag og bevegelsesfrihet i s730 Overekstremitetens struktur
skulderblad, bekken, håndrots- og s740 Bekkenregionens struktur
fotrotsknokler. s750 Underekstremitetens struktur
b730 Muskelstyrke s760 Bryst- og bukregionens og
Kraft oppstått ved sammentrekning av ryggens struktur
muskel eller muskelgruppe.
b735 Muskeltonus
Hvilespenning i muskler og musklenes
motstand mot passive bevegelser.
b740 Muskelutholdenhet
Opprettholdelse av
muskelsammentrekning i så lang tid som
det kreves.
b760 Kontroll av viljestyrte bevegelser
Kontroll og koordinasjon av viljestyrte
bevegelser.
b765 Ufrivillige muskelbevegelser
Utilsiktede, helt eller delvis
uhensiktsmessige ufrivillige
sammentrekninger av en muskel eller
muskelgruppe
b770 Gangmønster
Bevegelsesmønstre ved gang, løp eller
andre bevegelser av hele kroppen
b780 Sansefornemmelser i forbindelse med
muskler og bevegelsesfunksjoner
Sansefornemmelser i tilknytning til
muskler og muskelgrupper, og deres
bevegelser
b8 HUDEN OG TILHØRENDE
FUNKSJONER
b840 Hudens sansefornemmelser
Fornemmelser som kløe, svie og
parestesier
AKTIVITETSBEGRENSNINGER OG
DELTAGELSESINNSKRENKNINGER
d1 LÆRING OG
KUNNSKAPSANVENDELSE
d110 Betrakte
Tilsiktet bruk av synssansen, som å se
på en idrettsbegivenhet eller barn som
leker
d115 Lytte
Tilsiktet bruk av hørselssansen, som å
lytte på radio, musikk eller et foredrag
d140 Lære å lese
Utvikle ferdighet til å lese skriftlig
materiale (herunder blindeskrift) flytende
og nøyaktig, gjenkjenne bokstaver og
alfabet, fremsi ord med korrekt uttale, og
forstå ord og fraser
d145 Lære å skrive
Utvikle ferdighet til å fremstille symboler
(herunder blindeskrift) som representerer
lyder, ord eller fraser for å formidle
mening, som ved å stave riktig og bruke
god grammatikk
d150 Lære å regne
Utvikle ferdighet til å behandle tall og
utføre enkle og komplekse matematiske
operasjoner og anvende riktig
regnemetode for å løse et problem
d170 Skrive
Nedtegne symboler eller språk for å
formidle informasjon, som ved å
utarbeide en skriftlig redegjørelse for
hendelser eller idéer, eller lage et
brevutkast
d175 Løse problemer
Finne løsninger på spørsmål eller en
situasjon ved å identifisere og analysere
problemstillinger, utvikle valgmuligheter
og løsninger, bedømme mulige
virkninger av løsningene og iverksette en
valgt løsning, som ved å avgjøre en
meningsforskjell mellom to mennesker.
d2 ALLMENNE OPPGAVER OG KRAV
d210 Utføre en enkeltstående oppgave
Utføre enkle eller sammensatte og
koordinerte handlinger forbundet med
mentale og fysiske sider ved en
enkeltstående oppgave, som ved å
begynne på en oppgave, organisere tid,
plass og virkemidler for en oppgave,
bestemme tempoet i utførelsen, og
fullføre oppgaven, og holde ut under
gjennomføringen.
d220 Utføre multiple oppgaver
Utføre handlinger enkeltvis i rekkefølge
eller integrert og koordinert som ledd i
multiple, sammenhengende oppgaver
d230 Utføre daglige rutiner
Utføre enkle eller sammensatte og
koordinerte handlinger for å planlegge,
styre og fullføre det som kreves i
dagliglivets gjøremål eller plikter, som å
disponere tiden og legge planer for ulike
gjøremål gjennom hele dagen
d3 KOMMUNIKASJON
d310 Forstå talte ytringer
Forstå bokstavelig og underforstått
meningsinnhold i ytringer på talespråk,
som ved å forstå om et utsagn fastslår et
faktum eller er en talemåte
d315 Forstå ytringer uten ord
Forstå bokstavelig og underforstått
meningsinnhold i ytringer formidlet ved
fakter, symboler og tegninger, som å
forstå at et barn er søvnig når det gnir
seg i øynene eller at en varselklokke
betyr brannalarm
d330 Tale
Frembringe ord, fraser og lengre
ordsammenstillinger i talte ytringer med
bokstavelig og underforstått
meningsinnhold, som å gi uttrykk for et
faktum eller fortelle en historie med
talespråk
d335 Ytre seg uten ord
Bruke fakter, symboler og tegninger for å
formidle ytringer, som ved å riste på
hodet som uttrykk for uenighet eller
tegne et bilde eller diagram for å formidle
et faktum eller en sammensatt idé
d350 Samtale
Innlede, gjennomføre og avslutte en
utveksling av tanker og idéer ved hjelp
av tale, skrift eller andre former for
språk, med en eller flere personer, i
formell eller uformell sammenheng
d4 MOBILITET
d410 Endre grunnleggende kroppsstillinger
Innta en kroppsstilling og skifte til en
annen, og bevege seg fra en posisjon til
et annen, som ved å reise seg fra en stol
for å legge seg i sengen, bøye seg,
knele eller sette seg på huk, eller reise
seg fra disse stillingene
d415 Opprettholde en kroppsstilling
Bli værende i samme kroppsstilling etter
behov, som ved å bli sittende eller
stående i arbeidet eller på skolen
d420 Forflytte seg
Bevege seg fra et underlag til en annet,
som ved å gli langs en benk eller bevege
seg fra en seng til en stol, uten å endre
kroppsstilling
d430 Løfte og bære gjenstander
Løfte en gjenstand eller flytte noe fra et
sted til et annet, som ved å løfte en kopp
eller bære et barn fra et rom til et annet
d440 Finere håndbevegelser
Utføre koordinerte handlinger for å
håndtere gjenstander, plukke opp,
manipulere og slippe dem med hånd og
fingre, som ved å ta opp mynter fra et
bord, dreie en tallskive eller skru på en
bryter
d445 Bruke hender og armer
Utføre koordinerte handlinger for å
bevege gjenstander eller håndtere dem
med hender og armer, som ved å bruke
dørhåndtak eller kaste og ta imot en
gjenstand
d450 Gå
Bevege seg på et underlag til fots, skritt
for skritt, slik at en fot alltid er i kontakt
med underlaget, som ved å spasere,
rusle, og gå forover, bakover eller
sidelengs
d455 Bevege seg omkring
Flytte hele seg fra et sted til et annet
uten å gå, som ved å klatre, løpe, hinke,
småspringe, jogge, hoppe, slå kollbøtte,
eller løpe utenom hindere
d460 Bevege seg omkring på ulike steder
Gå og bevege seg omkring på ulike
måter og steder i forskjellige situasjoner,
som fra et rom til et annet i et hus eller
fra sted til sted utendørs
d465 Bevege seg omkring ved hjelp av
utstyr
Flytte hele kroppen fra sted til sted, på
hvilket som helst underlag eller område,
ved bruk av spesielt utstyr, som skøyter,
ski, dykkerutstyr, rullestol eller gåstol
d470 Bruke transportmidler
Bruke et transportmiddel som passasjer,
som i bil, buss, tog, trikk, båt eller
luftfartøy, eller transportmiddel drevet av
trekkdyr eller mannekraft
d475 Føre et transportmiddel
Føre et kjøretøy eller kjøretøyets
trekkdyr, reise med et hvilket som helst
transportmiddel som man kjører eller
styrer selv, som bil, sykkel eller båt
d5 EGENOMSORG
d510 Vaske seg
Bruke vann og passende midler og
metoder for å gjøre seg ren og tørke
seg, som ved å bade, dusje, vaske ulike
kroppsdeler, og bruke håndkle
d520 Stelle sine kroppsdeler
Stell av kroppsdeler som trenger mer
enn å vaskes og tørkes, som hud-, hår-,
ansikts- og tannpleie, stell av negler og
kjønnsorganer
d530 Gå på toalettet
Planlegge og utføre fjerning av
avfallsprodukter fra kroppen
(menstruasjonsprodukter, urin, avføring),
og gjøre seg ren etterpå
d540 Kle seg
Ta av og på klær og fottøy
overensstemmende med klimatiske og
sosiale forhold, som ved å ta på, rette på
og ta av seg alle slags klesplagg og
fottøy
d550 Spise
Dele opp, føre til munnen og innta
servert mat på kulturelt akseptabel måte,
åpne matvareemballasje, bruke
spiseredskaper, innta måltider til
hverdags og fest
d560 Drikke
Gripe, føre til munnen og innta en
drikkevare på kulturelt akseptabel måte,
blande og skjenke drikkevarer, åpne
emballasjen, bruke sugerør, eller drikke
rennende vann fra en kran eller kilde,
men også å die
d570 Ta vare på helsen
Sikre helse, fysisk og psykisk velvære,
som ved et balansert kosthold, passende
fysisk aktivitet, holde seg varm eller
avkjølt, unngå helseskade, ha sikre
seksualvaner, herunder bruk av kondom,
la seg vaksinere og gjennomgå
regelmessig helsekontroll
d6 HJEMMELIV
d620 Skaffe seg varer og tjenester
Velge ut, anskaffe og transportere alle
varer og tjenester som er nødvendige i
dagliglivet, og lagre varene, som mat,
drikkevarer, klær, rengjøringsmidler,
brensel, husholdningsgjenstander,
redskaper, kokekar,
husholdningsapparater og verktøy,
skaffe seg tekniske tjenester og andre
husholdningstjenester
d630 Lage mat
Planlegge, organisere, tilberede og
servere enkle og sammensatte måltider
for seg selv og andre, som ved å sette
opp en meny, velge ut mat og drikke,
samle sammen ingredienser til matretter,
koke og steke, tilberede kald mat og
drikkevarer, og servere mat og drikke
d640 Husarbeid
Være ansvarlig for et hjem når det
gjelder rengjøring og rydding av rom og
inventar, vask, stell og vedlikehold av
klær og skotøy, bruk av
husholdningsapparater, å kaste avfall
d650 Ta vare på husholdningsgjenstander
Vedlikeholde og reparere
husholdningsgjenstander og personlige
eiendeler, innbo, klær, kjøretøy og
tekniske hjelpemidler, ta vare på planter
og husdyr, som ved å male eller
tapetsere, reparere møbler,
vannforsyning og avløp, vanne planter,
stelle og mate husdyr
d660 Hjelpe andre
Hjelpe medlemmer av husholdningen og
andre personer med å lære,
kommunisere, ta vare på seg selv, og
bevege seg omkring, i huset eller
utenfor, være opptatt av husstandens og
andres velvære

d7 MELLOMMENNESKELIGE
INTERAKSJONER OG RELASJONER
d710 Grunnleggende mellommenneskelige
interaksjoner
Interaksjon med mennesker tilpasset
situasjon og sosiale krav, som ved å ta
hensyn og gi anerkjennelse når det er på
sin plass, eller reagere på andres
følelser
d720 Sammensatte mellommenneskelige
interaksjoner
Opprettholde og mestre interaksjoner
med andre mennesker, tilpasset
situasjon og sosiale krav, som ved å ha
kontroll over følelsesuttrykk og impulser,
ha kontroll over verbal og fysisk
aggresjon, handle uavhengig i sosiale
interaksjoner, og handle i
overensstemmelse med sosiale regler
og sedvaner
d730 Forholde seg til fremmede personer
Inngå i midlertidige kontakter og
forbindelser med fremmede personer for
bestemte formål, som ved å spørre om
veien eller gjøre et innkjøp
d740 Formelle mellommenneskelige
relasjoner
Skape og opprettholde særskilte
personlige forhold i formell
sammenheng, som med arbeidsgivere,
fagpersoner eller tjenesteytere
d750 Uformelle sosiale relasjoner
Inngå i personlige forhold til andre, som
ved tilfeldige forhold til personer som bor
i samme nærsamfunn eller boligområde,
eller med medarbeidere, studenter,
lekekamerater eller personer med
lignende bakgrunn eller yrke
d760 Familierelasjoner
Skape og opprettholde forbindelser med
slekten, som med medlemmer av
kjernefamilien, fjernere familie, foster- og
adoptivfamilie, stebarn eller steforeldre,
fjernere forhold som med tremenninger
eller formyndere
d770 Intime relasjoner
Innlede og opprettholde nære eller
romantiske forhold mellom personer,
som ektefeller, kjærester eller
seksualpartnere
d8 VIKTIGE LIVSOMRÅDER
d810 Uformell opplæring
Læring i hjemmet eller på annen måte
utenfor utdanningsinstitusjon, som å
lære håndverk og andre ferdigheter av
foreldre eller familiemedlemmer, eller
skoleundervisning i hjemmet
d820 Skoleutdanning
Bli opptatt i skole, delta i alle
skolerelaterte plikter og rettigheter,
tilegne seg fagstoff og pensum i
barneskolen og senere skoletrinn,
herunder møte frem regelmessig på
skolen, delta i samarbeid med andre
elever, motta veiledning fra lærere,
organisere, sette seg inn i og fullføre
tildelte oppgaver og prosjekter, og gå
videre til høyere utdanningsnivå
d830 Høyere utdanning
Delta i aktivitetene i et avansert
utdanningsprogram ved universitet,
høyskole eller akademisk fagutdanning
og tilegne seg alt pensum som kreves
for å oppnå akademisk grad, diplom,
sertifikat eller annen offentlig
godkjenning, som ved å fullføre en
mellomfags- eller hovedfagsutdanning
ved universitet, medisinerutdanning eller
annen akademisk fagutdanning.
d850 Betalt sysselsetting
Delta i alle sider av arbeidet i et yrke,
håndverk, akademisk fag eller annen
sysselsetting, for betaling, som ansatt på
hel tid eller deltid, eller som egen
arbeidsgiver, som ved å søke arbeid og
skaffe seg en jobb, utføre de nødvendige
arbeidsoppgaver, møte frem på arbeidet
i tide, utføre og motta supervisjon, og
utføre de oppgaver som kreves, alene
eller i gruppe
d860 Grunnleggende økonomiske
transaksjoner
Delta i enkle økonomiske transaksjoner,
som å kjøpe mat for penger eller ved
byttehandel, utveksling av varer eller
tjenester, eller å spare penger
d870 Være økonomisk selvhjulpen
Ha rådighet over økonomiske ressurser
fra private eller offentlige kilder, for å
sikre økonomisk trygghet for nåværende
og fremtidige behov
d9 SAMFUNNSLIV OG SOSIALE
LIVSOMRÅDER
d910 Samfunnsliv
Delta i alle sosiale livsområder i
samfunnet, som ved å delta i veldedige
organisasjoner, sosiale klubber og
organisasjoner for yrkesgrupper eller
samfunnslag
d920 Rekreasjon og fritid
Delta i all slags lek og spill, rekreasjons-
eller fritidsaktiviteter, som uformell eller
organisert lek og sport, fysiske
treningsprogrammer, avkobling,
fornøyelse eller adspredelse, gå på
kunstgalleri, museum, kino eller teater,
delta i husflid og hobbyer, lese for
fornøyelsens skyld, spille på
musikkinstrumenter, sightseeing, turisme
og reisevirksomhet
d930 Religion og åndelighet
Delta i religiøse eller åndelige aktiviteter,
organisasjoner og livsførsel, for å oppnå
egne mål, for å finne mening i livet,
religiøse eller åndelige verdier, og å
oppnå kontakt med en guddommelig
makt, som ved å være tilstede i gudshus
 som kirke, tempel, moské eller
synagoge, delta i eller utøve bønn eller
religiøs messe, og åndelig
kontemplasjon
d940 Menneskerettigheter
Nyte godt av rettigheter, beskyttelse,
privilegier og plikter som tilkommer
personer utelukkende i kraft av at de er
mennesker, som ved
menneskerettigheter slik de er anerkjent
i FNs menneskerettighetserklæring
(1948) og FNs standardregler for like
muligheter for mennesker med
funksjonshemming (1993), retten til
selvbestemmelse eller uavhengighet,
retten til kontroll over sin egen skjebne
d950 Politisk liv og statsborgerskap
Delta i en borgers liv i samfunnet,
politikken og styresettet, ha juridisk
status som statsborger, og nyte godt av
borgerrettigheter, beskyttelse, privilegier
og samfunnsplikter, som stemmerett,
valgbarhet til politiske verv og rett til å
danne politiske foreninger, utøve
borgerrettigheter som ytringsfrihet,
organisasjonsfrihet, religionsfrihet,
beskyttelse mot urettmessig ransaking
og beslag, rett til juridisk bistand og til å
føre sin sak for retten, andre juridiske
rettigheter og rett til beskyttelse mot
diskriminering, ha juridisk status som
statsborger
HEMMENDE ELLER FREMMENDE
MILJØFAKTORER
e1 PRODUKTER OG TEKNOLOGI
e110 Produkter eller substanser til å spise
eller drikke
Enhver naturlig eller menneskeskapt
gjenstand eller substans som er
innsamlet, bearbeidet eller fremstilt for å
spises eller drikkes
e115 Produkter og teknologi til personlig
bruk i dagliglivet
Utstyr, produkter og teknologier som
benyttes i dagliglivet, herunder slike som
er tilpasset eller spesielt utformet, og
som befinner seg i, på eller i nærheten
av personen som benytter dem
e120 Produkter og teknologi for personlig
mobilitet og transport innen- og
utendørs
Utstyr, produkter og teknologier som
benyttes til å bevege seg omkring innen-
og utendørs, herunder slike som er
tilpasset eller spesielt utformet, og som
befinner seg i, på eller i nærheten av
personen som benytter dem
e125 Produkter og teknologi for
kommunikasjonsformål
Utstyr, produkter og teknologi som
brukes til å sende og motta informasjon,
herunder slike som er tilpasset eller
spesielt utformet, og som befinner seg i,
på eller i nærheten av personen som
benytter dem
e150 Utforming, konstruksjon, produkter
og teknologi for bygninger til offentlig
bruk
Produkter og teknologi som utgjør det
menneskeskapte innen- og utendørs
miljø for allmenhetens bruk, herunder
slike som er tilpasset eller spesielt
utformet
e155 Produkter og teknologi for utforming
og konstruksjon av bygninger til
privat bruk
Produkter og teknologi som utgjør det
menneskeskapte innen- og utendørs
miljø for privat bruk, herunder slike som
er tilpasset eller spesielt utformet
e225 Klima
Meterologiske egenskaper og hendelser,
for eksempel været
e240 Lys
Elektromagnetisk stråling som gjør ting
synlige, enten ved sollys eller kunstig
belysning (for eksempel stearinlys, olje-
eller parafinlamper, ildsteder og elektrisk
lys), og som kan gi nyttig eller
forstyrrende informasjon om
omverdenen
e250 Lyd
Fenomener som høres eller kan høres,
som brak, ringelyder, bankelyder, sang,
 fløyting, skrik eller summing, uansett
lydstyrke, klang og toneleie, som kan gi
nyttig eller forstyrrende informasjon om
omverdenen
e3 STØTTE OG SOSIALT NETTVERK
e310 Nærmeste familie
Individer som er i familie ved fødsel,
ekteskap eller andre forhold regnet som
nærmeste familieforhold i den aktuelle
kultur, som ektefeller, partnere, foreldre,
søsken, avkom, fosterforeldre,
adoptivforeldre og besteforeldre
e320 Venner
Personer som er nære og vedvarende
deltagere i forhold kjennetegnet ved tillit
og gjensidig støtte
e325 Bekjente, likemenn, kolleger, naboer
og medlemmer av nærsamfunnet
Personer som kjenner hverandre som
bekjente, likemenn, kolleger, naboer og
medlemmer av nærsamfunnet, i
arbeidssituasjoner, skole, rekreasjon
eller andre livsområder, og som deler
demografiske egenskaper som alder,
kjønn, religiøs oppfatning, etnisitet eller
som dyrker felles interesser
e330 Personer i autoritetsposisjon
Personer som har ansvar for å treffe
beslutninger for andre og som har sosialt
bestemt innflytelse eller makt i kraft av
sine sosiale, kulturelle eller religiøse
roller i samfunnet, som lærere,
arbeidsgivere, overordnede i
arbeidslivet, religiøse ledere, personer
som tar beslutninger på vegne av andre,
formyndere eller fullmektiger i juridisk
eller økonomisk forbindelse
e340 Personer som yter personlig omsorg
og hjelp
Personer som utfører tjenester for å
støtte en person i dagliglivets gjøremål
og i å opprettholde yteevne i arbeid,
utdannelse eller andre livssituasjoner, og
som stilles til rådighet ved offentlige eller
private midler, eller eventuelt på frivillig
grunnlag, som hjemmehjelps- og
omsorgspersonale,
transportmedhjelpere, betalte hushjelper,
barnepiker og andre som har primære
omsorgsfunksjoner
e355 Helsepersonell
Alle tjenesteytere som arbeider i
sammenheng med helsevesenet, som
leger, sykepleiere, fysioterapeuter,
ergoterapeuter, logopeder,
audioteknikere, protesemakere,
sosionomer og andre slike tjenesteytere
e360 Helserelaterte fagpersoner
Alle tjenesteytere som arbeider utenom
helsevesenet, men som leverer
helserelaterte tjeneste, som
sosialarbeidere, lærere, arkitekter eller
designere
e4 HOLDNINGER
e410 Individuelle holdninger hos nærmeste
familiemedlemmer
Allmenne og særskilte oppfatninger og
overbevisninger hos nærmeste
familiemedlemmer om personen eller om
andre spørsmål (som sosiale, politiske
og økonomiske temaer) som påvirker
individuell atferd og handlinger
e420 Individuelle holdninger hos venner
Allmenne og særskilte oppfatninger og
overbevisninger hos venner om
personen eller om andre spørsmål (som
sosiale, politiske og økonomiske temaer)
som påvirker individuell atferd og
handlinger
e425 Individuelle holdninger hos bekjente,
likemenn, kolleger, naboer og
medlemmer av nærsamfunnet
Allmenne og særskilte oppfatninger og
overbevisninger hos bekjente, likemenn,
kolleger, naboer og medlemmer av
nærsamfunnet om personen eller om
andre spørsmål (som sosiale, politiske
og økonomiske temaer) som påvirker
individuell atferd og handlinger
e430 Individuelle holdninger hos personer i
autoritetsposisjon
Allmenne og særskilte oppfatninger og
overbevisninger hos personer i
autoritetsposisjon om personen eller om
andre spørsmål (som sosiale, politiske
og økonomiske temaer) som påvirker
individuell atferd og handlinger
e435 Individuelle holdninger hos personer i
posisjon som underodnet
Allmenne og særskilte oppfatninger og
overbevisninger hos personer i posisjon
som underodnet om personen eller om
andre spørsmål (som sosiale, politiske
og økonomiske temaer) som påvirker
individuell atferd og handlinger
e440 Individuelle holdninger hos personer
som yter personlig omsorg og hjelp
Allmenne og særskilte oppfatninger og
overbevisninger hos personer som yter
personlig omsorg og hjelp om personen
eller om andre spørsmål (som sosiale,
politiske og økonomiske temaer) som
påvirker individuell atferd og handlinger
e450 Individuelle holdninger hos
helsepersonell
Allmenne og særskilte oppfatninger og
overbevisninger hos helsepersonell om
personen eller om andre spørsmål (som
sosiale, politiske og økonomiske temaer)
som påvirker individuell atferd og
handlinger
e455 Individuelle holdninger hos
helserelaterte fagpersoner
Allmenne og særskilte oppfatninger og
overbevisninger hos helserelaterte
 fagpersoner om personen eller om andre
spørsmål (som sosiale, politiske og
økonomiske temaer) som påvirker
individuell atferd og handlinger
e460 Holdninger i samfunnet
Allmenne og særskilte oppfatninger og
overbevisninger om andre mennesker
eller om sosiale, politiske og økonomiske
spørsmål, som holdes av personer i en
kultur, et samfunn, en subkultur eller
annen sosial gruppe, og som påvirker
atferd og handlinger hos individer eller
grupper
e465 Sosiale normer, handlingsmønstre og
ideologier
Skikker, handlingsmønstre, regler,
abstrakte verdisystemer og
retningsgivende overbevisninger (som
ideologier, livssyn og moralfilosofi) som
oppstår i sosial sammenheng og som
påvirker eller skaper handlingsmønstre og
atferd i samfunnet og hos
enkeltmennesker, som sosiale
moralnormer, etikette og religiøs atferd,
religiøs doktrine med resulterende normer
og handlingsmønstre, normer som styrer
ritualer eller sosiale sammenkomster
e5 TJENESTER, SYSTEMER OG
STRATEGIER FOR TILTAK
e515 Tjenester, systemer og strategier for
arkitektur og byggevirksomhet
Tjenester, systemer og strategier for
utforming og oppføring av offentlige og
private bygninger
e525 Tjenester, systemer og strategier for
boligsektoren
Tjenester, systemer og strategier for å
skaffe folk et sted å bo
e535 Tjenester, systemer og strategier for
kommunikasjon
Tjenester, systemer og strategier for
overføring og utveksling av informasjon
Tjenester, systemer og strategier for
transport
e540
Tjenester, systemer og strategier for
person- og varetransport
e550 Tjenester, systemer og strategier for
lov og rett
Tjenester, systemer og strategier
vedrørende lovgivingen i et land
e560 Tjenester, systemer og strategier for
media
Tjenester, systemer og strategier for
massekommunikasjon gjennom radio,
fjernsyn, aviser og Internett
e570 Tjenester, systemer og strategier for
trygdevesen
Tjenester, systemer og strategier med
sikte på å gi inntektsstøtte til mennesker
som på grunn av alder, fattigdom,
arbeidsløshet, helsetilstand eller
funksjonshemming trenger offentlig
stønad som finansieres enten ved
allmenn skatteinntekt eller
bidragsordninger
e575 Tjenester, systemer og strategier for
allmenn sosial omsorg
Tjenester, systemer og strategier med
sikte på å skaffe støtte til personer som
trenger hjelp på områder som innkjøp,
husarbeid, transport, egenomsorg og
omsorg for andre, for å fungere best
mulig i samfunnet
e580 Tjenester, systemer og strategier for
helsevesen
Tjenester, systemer og strategier for å
forebygge og behandle helseproblemer,
gi medisinsk rehabilitering og fremme
sunne levevaner
e585 Tjenester, systemer og strategier for
utdanning og opplæring
Tjenester, systemer og strategier for
tilegnelse, vedlikehold og forbedring av
kunnskap, ekspertise og yrkesmessige
eller kunstneriske ferdigheter, Se
UNESCO's International Standard
Classification of Education (ISCED),
November 1997, vedrørende detaljer om
nivåer i utdanningsprogrammer. Norsk
standard overensstemmende med
ISCED 1997 er "Norsk standard for
utdanningsgruppering" (NUS2000)
e590 Tjenester, systemer og strategier for
arbeid og sysselsetting
Tjenester, systemer og strategier for
arbeidsformidling til personer som er
arbeidsløse eller ønsker å skifte arbeid,
eller for å støtte personer som er i arbeid
og søker forfremmelse
 Shoulder Activity Scale
Score (circle the most relevant)
Test Procedure Instruction NO MILD MODERATE SEVERE CANNOT
DIFFICULTY DIFFICULTY DIFFICULTY DIFFICULTY PERFORM
From a standing or sitting position the subject Lift the object up on the
lifts a 1 kg object from a table to a high shelf. shelf and back on the table
1. Lifting an The task is repeated three times without a three times.
object to a break. The height of the shelf should be 1 2 3 4 5
shelf slightly above the subjects head and the
difference in height between the table and
the shelf at least 0.7 meters.
Test 2: From a standing or sitting position the Put on the jacket with the
subject puts on a jacket with the healthy arm healthy arm in the first
2. Putting on
in the first sleeve and then off beginning with sleeve and take it off with 1 2 3 4 5
a jacket the painful arm. The jacket should be medium the painful arm first.
tight and made of non-stretchy material.
From a sitting position with approximately 90 Lift the object up from the
degrees angle in the hip and knee the subject desk to shoulder height with
lifts a 2 kg object with a straight and a straight arm. Keep the
approximately 90 degrees internal rotated upper body stable. Move the
arm, from a table in front and to the height of object sideways until the
3. Moving an the shoulder. The arm is now at 90 degrees arm is outside the shoulder,
flexion, internal rotated in a sagittal plane. and then back to forward
1 2 3 4 5
arm sideways
The straight arm is abducted to the frontal position. Keep the arm at
plane, and adducted to the sagittal plane shoulder level and straight
without allowing any variation in the height through the movement. The
or the rotation of the arm. The task is task is repeated once
repeated once without a break. without a break.

SUM-SCORE 1. + 2. + 3. =____ points